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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423630
Report Date: 12/10/2024
Date Signed: 12/10/2024 02:37:24 PM

Document Has Been Signed on 12/10/2024 02:37 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MEMBERS CLUB RESIDENTIAL CAREFACILITY NUMBER:
336423630
ADMINISTRATOR/
DIRECTOR:		NIKKI VON JENAFACILITY TYPE:
735
ADDRESS:38516 MEMBERS CLUB DRIVETELEPHONE:
(951) 319-6719
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 4CENSUS: 4DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Penty SimbolonTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by Caregiver Penty Simbolon, notified her of the purpose for the visit and was allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a two stories building with four (4) residents bedrooms, 1 staff bedroom and 2.5 bathrooms. There is no gated pool and there are no firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen area inaccessible to residents. The smoke detector and carbon monoxide detector were operational. LPA observed fire extinguishers to be in compliance with the department requirements and with an expiration date of June 14, 2025. LPA observed the hot water temperature to meet requirements at 119.1°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.


Continued on LIC809-C.....
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MEMBERS CLUB RESIDENTIAL CARE
FACILITY NUMBER: 336423630
VISIT DATE: 12/10/2024
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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of April 14th, 2026 and a CPR certification with the expiration date of September 11, 2026

Record Review and Resident/Staff Files: LPA reviewed files for Three(3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Four (4) residents' files were reviewed and contained all required documentation. LPA observed first aid kit, Staff and resident files to be locked and stored in the office in the hallway.


Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the office. LPA reviewed medications for four residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 11-05-2024, which met department requirements. All facility exits were clear of obstructions.


No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to administrator Nikki Von Jena.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
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