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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424626
Report Date: 09/19/2024
Date Signed: 09/20/2024 08:10:54 AM

Document Has Been Signed on 09/20/2024 08:10 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:PLEASANT GROVE RESIDENTIALFACILITY NUMBER:
336424626
ADMINISTRATOR/
DIRECTOR:		KEITH WALKERFACILITY TYPE:
735
ADDRESS:25183 TODD DRIVETELEPHONE:
(951) 924-2300
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 4DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Administrator Desean WalkerTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 9/19/24 Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced one (1) year required visit. LPA was granted entry by driver, Rogerella Loza, who was informed of the purpose of visit. At the time of the inspection, there were no clients present as they were at day program and Administrator came to assist. All staff were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA Flores observed the following during today's visit:

LPA Flores conducted a tour of the facility and observed the physical plant was a single-story structure containing four (4) resident bedrooms and two (2) bathrooms. The facility has a formal dining rooms, kitchen, living room, staff office, garage, and a gated backyard. Indoor and outdoor passageways were free of obstruction. There were no bodies of water located on the property. The facility has more than a two (2) day supply of perishable food and seven (7) day supply of non-perishable foods. Dishes and utensils were in sufficient supply and in good repair. Garage had an additional refrigerator and freezer with sufficient amount of food. Knives and other sharp items are located in a locked cabinet near the kitchen. Resident bedrooms had the required bedding, furniture, and lighting. The smoke and carbon monoxide detectors were tested and were observed to be operable. Centrally stored medication was observed in a locked cabinet in the staff office. Two (2) fully charged fire extinguishers were observed in the facility. The facility was observed to be in a clean condition; free of dirt, insects, rodents, and pests. According to Administrator, Desean, there are no firearms or ammunition on the premises.


Staff files reviewed included but not limited to having a personnel record, health screening, criminal record clearance, and valid CPI Certification. Resident files included but are not limited to signed admission agreements, placement, personal rights, CDER, weight charts, and updated physician reports. Facility sketch, LTCO, CCL complaint poster, and emergency disaster plan is posted on a wall near the hallway.



During today's visit, LPA did not observe any immediate violations or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided to the Administrator, Desean Walker.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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