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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413183
Report Date: 10/13/2023
Date Signed: 10/13/2023 05:15:50 PM

Document Has Been Signed on 10/13/2023 05:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROXIE'S CARE FACILITYFACILITY NUMBER:
336413183
ADMINISTRATOR:YVONNE HOLCOMBEFACILITY TYPE:
735
ADDRESS:25704 MARGARET AVENUETELEPHONE:
(951) 242-2841
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 2DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:53 PM
MET WITH:ADMINISTRATOR, YVONNE HOLCOMBETIME COMPLETED:
05:23 PM
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On October 13, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection and met with the Administrator, Yvonne Holcombe. The LPA introduced herself, and stated the purpose of the visit.

LPA Mixson toured the facility along with the Administrator and inspected the facility inside and outside there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single story home, located at 25704 Margaret Avenue Moreno Valley, CA 92551. Physical Plant: The facility phone number is (951) 242-2841 and is operable. The LPA observed the resident bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected the facility bathrooms, and the hot water temperature tested within regulations. Bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required posting "Personal Rights" and other postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents. There was a designated storage space for the resident and staff files. Medications: were locked, inaccessible to residents, and had at least a 30 day supply. The overall facility is clean, the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision: Facility has sufficient staff, two staff at the time of this visit, and staff were engaging the residents. Records Review: The LPA reviewed two resident files, and one staff file. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit.
An exit interview was conducted and a copy of this report, along with the LIC 811, was given to the Administrator, Yvonne Holcombe.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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