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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425144
Report Date: 09/19/2024
Date Signed: 09/20/2024 08:13:12 AM

Document Has Been Signed on 09/20/2024 08:13 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:APOSTOL FAMILY HOME LLC IFACILITY NUMBER:
336425144
ADMINISTRATOR/
DIRECTOR:		APOSTOL, ROSAMILAFACILITY TYPE:
735
ADDRESS:16245 EMMA LANETELEPHONE:
(951) 242-9487
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 4CENSUS: 3DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Licensee Rosamila ApostolTIME VISIT/
INSPECTION COMPLETED:
04:20 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 Licensee, Rosamila Apostol, who was informed of the purpose of visit. At the time of the visit there were one (1) staff, Administrator/Licensee and two (2) residents present. All staff present 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 with Licensee, Rosamila. The physical plant is a two-story structure that contained two (2) resident bedrooms, three (3) rooms designated for Licensee's family, and three (3) bathrooms. The facility has a formal dining rooms, kitchen, living room, family room, 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. Extra linen were observed in the closet located in the hallway. There is a refrigerator observed in the garage that was observed to be fully stocked. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items were observed in a locked cabinet underneath the kitchen sink. 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 kitchen. The outdoor patio was observed to have shaded seating to encourage outdoors socialization. A 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/Licensee, Rosamila, there are no firearms or ammunition on the premises.



Continuation on LIC809C...
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)
Page: 1 of 2
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: APOSTOL FAMILY HOME LLC I
FACILITY NUMBER: 336425144
VISIT DATE: 09/19/2024
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Staff files reviewed include but not limited to have employee applications, health screenings, criminal record clearance, job-related trainings, and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, weight logs, and updated physician reports. P&I and Medication Administration Record (MAR) was reviewed and no discrepancies were observed. Facility conducted monthly disaster training's (i.e. earthquake and fire drills). Facility sketch, LTCO, CCL complaint poster, license and house rules were posted on the walls throughout the facility.

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 Licensee, Rosamila.
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
LIC809 (FAS) - (06/04)
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