<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424626
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:48:29 PM

Document Has Been Signed on 10/10/2023 01:48 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:PLEASANT GROVE RESIDENTIALFACILITY NUMBER:
336424626
ADMINISTRATOR:KEITH WALKERFACILITY TYPE:
735
ADDRESS:25183 TODD DRIVETELEPHONE:
(951) 924-2300
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: DATE:
10/10/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:House Manager, DeSean WalkerTIME COMPLETED:
02:00 PM
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
On 10/10/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct a Plan of Correction (POC) visit from a deficiency observed by LPA on 9/19/2023's visit at the facility. LPA me with House Manager, DeSean Walker who was informed of the purpose of visit. LPA conducted a tour of the facilty's interior and exterior.

On 9/19/2023, LPA visited the facility to conduct an annual required inspection. LPA measured the water temperature in the facility bathrooms, which measured at 151-degrees Fahrenheit. Licensee's POC was to regulate the hot water temperature in the facility bathrooms to allow clients to attain a hot water temperature between 105- and 120-degrees F.

On 10/10/2023, LPA measured the water temperatures in both facility bathrooms, which measured at 113- and 119- degrees Fahrenheit. LPA will clear the POC and issued a POC clearance letter to House Manager Walker.

During today's, LPA did not observe any additional deficiencies faulting the facility.

An exit interview was conducted and a copy of this report was reviewed and provided to House Manager Walker.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1