336424317-1-9-2025-18-AS-AZEO-DCRS2E-20250109122923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424317
Report Date: 01/09/2025
Date Signed: 01/09/2025 12:29:30 PM

Document Has Been Signed on 01/09/2025 12:29 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:	SAMUEL HOME		FACILITY NUMBER:	336424317
ADMINISTRATOR/ DIRECTOR:	SANDRA HERNANDEZ		FACILITY TYPE:	735
ADDRESS:	41367 TRUMBLE COURT		TELEPHONE:	(760) 289-6014
CITY:	INDIO	STATE: CA	ZIP CODE:	92203
CAPACITY: 6		CENSUS: 4	DATE:	01/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Yazmine Muneton		TIME VISIT/ INSPECTION COMPLETED:	12:40 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 Yazmine Muneton, 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, one(1) activity room, three(3) bathrooms, an office, a living room and a kitchen area. 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 garage 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 September 20, 2025. The water temperature was measured at 113.1 F, meeting the department's requirement

Continued 809-C......

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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: 01/09/2025

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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 September 16, 2026 and a CPR certification with the expiration date of November 4th, 2026

Record Review and Resident/Staff Files: LPA reviewed files for four(4) 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 to be locked and stored in the living room area. The residents files were kept in a locked cabinet next to the kitchen area and the staff files were kept in a locked cabinet in the garage.

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the living room. 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 1-1-2025, 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 Alexi Garcia.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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