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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413298
Report Date: 10/04/2022
Date Signed: 10/04/2022 08:48:16 AM


Document Has Been Signed on 10/04/2022 08:48 AM - 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:GOOD SAMARITAN ELDERLY HOME IIFACILITY NUMBER:
336413298
ADMINISTRATOR:EFREN/MELDY CARREONFACILITY TYPE:
740
ADDRESS:12145 WESTERLY TRAILTELEPHONE:
(951) 243-7479
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 3DATE:
10/04/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Meldy Carreon, AdministratorTIME COMPLETED:
08:48 AM
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Licensing Program Analyst (LPA), Stephanie Torres, arrived unannounced to the facility to conduct a case management visit to check on the health, safety, and welfare of residents in care. LPA met with Administrator, Meldy Carreon, and explained the purpose of the visit.
Three (3) residents in care were present during visit. The LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. The LPA assessed the available food supply and observed the home to meet the required two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well.

No imminent health and/or safety concerns were observed at the time of visit. No deficiencies were cited during today’s visit.

An exit interview was conducted with Carreon and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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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