336425144-9-20-2023-18-AS-JROO-CVUTQM-20230920145609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425144
Report Date: 09/20/2023
Date Signed: 09/20/2023 02:56:13 PM

Document Has Been Signed on 09/20/2023 02:56 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	APOSTOL FAMILY HOME LLC I		FACILITY NUMBER:	336425144
ADMINISTRATOR:	APOSTOL, ROSAMILA		FACILITY TYPE:	735
ADDRESS:	16245 EMMA LANE		TELEPHONE:	(951) 242-9487
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92551
CAPACITY: 4		CENSUS: 3	DATE:	09/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Licensee Rosamila Apostol		TIME COMPLETED:	03:00 PM

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On 9/20/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA met with Licensee Rosamila Apostol. During the visit, there was one (1) client and one (1) staff present, and LPA was informed that two (2) clients were at day program.

The facility is approved to care for four (4) ambulatory clients and serves adults ages 18 through 59. LPA toured the facility's interior and exterior with Licensee Apostol.

During the visit, LPA observed the following:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. The facility had a 2-day supply of perishable food items and 7-day supply of non-perishable food items. Knives and cleaning solutions are secured in a locked kitchen cabinet.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. Activities and board games are available for clients.

Hallway: Hallway was clean with no pathway obstruction. LPA observed fire alarms throughout the facility. Carbon monoxide and smoke detector were tested and functioning properly. Fire extinguisher was charged and mounted near the kitchen.

Continue on LIC809-C

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APOSTOL FAMILY HOME LLC I	FACILITY NUMBER: 336425144
	VISIT DATE: 09/20/2023

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Continued from LIC809.

Centrally Stored Medications: LPA observed two (2) first aid kits with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for the clients as well as the Medication Administration Record (MAR) used to log administration of clients’ medications. No discrepancies discovered.

Records: Staff present has a criminal record clearance on file and is associated to the facility. Staff training is up to date. The facility's last earthquake and fire drill was conducted on 9/16/2023.

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with nonskid mats in the shower. The hot water temperature in the clients' bathroom measured at 111-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry/Garage: LPA toured the garage. Washing machine and dryer are in good repair and stored in the garage. Emergency food and water are also stored in the garage.

Yard/Outside Area: A wood wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

During today's visit, LPA did not observe any deficiencies. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Apostol.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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