336413304-10-20-2023-18-AS-CGOH-CWSN53-20231020100853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336413304
Report Date: 10/20/2023
Date Signed: 10/20/2023 10:09:03 AM

Document Has Been Signed on 10/20/2023 10:09 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	EBEN HAVEN		FACILITY NUMBER:	336413304
ADMINISTRATOR:	ELIZABETH ODUNJO		FACILITY TYPE:	740
ADDRESS:	30792 STONE CREEK CT.		TELEPHONE:	(951) 679-7754
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY:	6	CENSUS: 4	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Administrator, Elizabeth Odunjo		TIME COMPLETED:	10:08 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 8:48 am to conduct an unannounced annual visit. LPA met the Caregiver Angelica Alamillo Ochoa at the front door and was granted entry. The Administrator, Elizabeth Odunjo arrived at 9:07am. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. The facility is a single-story home located in a residential area in Menifee, CA licensed to serve six (6) non-ambulatory and approved for 1 bedridden with 4 residents in care. The facility has a Hospice Waiver for 4 residents. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility temperature read at 73 degrees. The facility consists of 4 resident bedrooms, and 3 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with lighting, closet space, tv and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 110 degrees which is within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the hallway and inaccessible to the resident. The facility has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings. Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, client rights, and admissions agreements. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EBEN HAVEN	FACILITY NUMBER: 336413304
	VISIT DATE: 10/20/2023

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(Continued from LIC809)

Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has a medication logbook; the facility documents the resident’s medication and in is compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 09/23/23. The facility has emergency supply of food and water.
Summary: No deficiencies were observed at the time of the visit. An exit interview was conducted and a copy of this report was provided to Administrator, Elizabeth Odunjo and her signature on this form confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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