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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424317
Report Date: 01/09/2024
Date Signed: 01/09/2024 11:37:28 AM

Document Has Been Signed on 01/09/2024 11:37 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SAMUEL HOMEFACILITY NUMBER:
336424317
ADMINISTRATOR:SANDRA HERNANDEZFACILITY TYPE:
735
ADDRESS:41367 TRUMBLE COURTTELEPHONE:
(760) 289-6014
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 6CENSUS: 4DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:House Lead Staff, Alexi GarciaTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with House Lead Staff, Alexi Garcia, who was informed of the purpose of the visit. At time of visit there were (2) clients and (3) staff present.

The facility is a two story home with (5) bedrooms and (3) bathrooms with attached garage. The facility does have not a pool or fire arms. The facility is designated as an adult residential home, serving adults between the ages of 18-59 years of age. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to mitigate the spread of infectious diseases and a plan to train staff.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The carbon monoxide detectors were operational, and the hot water temperature was recorded at 120.5F. LPA observed hygiene supplies, linens and laundered clothing. The home was a comfortable temperature during the time of the visit.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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: SAMUEL HOME
FACILITY NUMBER: 336424317
VISIT DATE: 01/09/2024
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ecord Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in the laundry room. LPA reviewed client medications for clients and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted 1/1/24. LPA observed all facility exits were clear from obstructions.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to House Lead Staff, Alexi Garcia
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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