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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425145
Report Date: 02/11/2025
Date Signed: 02/11/2025 03:30:39 PM

Document Has Been Signed on 02/11/2025 03:30 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:APOSTOL FAMILY HOME LLC IIFACILITY NUMBER:
336425145
ADMINISTRATOR/
DIRECTOR:		APOSTOL, ROSAMILAFACILITY TYPE:
735
ADDRESS:24922 BRANCH ST.TELEPHONE:
(951) 208-0978
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 3DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Staff, Vanessa LucenaTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Janira Arreola and Abdoulaye Zerbo conducted an unannounced annual required visit. LPA was granted entry and met with staff and were later joined by designated staff in charge Vanessa Lucena. The Licensee Jaime Apostol was available over the phone and were informed of the purpose of the visit. At the time of the visit there was (23) staff and (3) clients present.

The facility is a one story home with (4) bedrooms and (2) bathrooms for residents and (2) bedrooms for staff. No pools or firearms are being kept at the facility. The facility is an adult residential facility. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.



Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed and fixtures and furniture were in good were present. The outdoor area was observed to be free of hazards. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational. The hot water temperature was initially read at 138.5F, which was then adjusted and read at the end of the visit at 125.3F. The facility was cited and a plan of correction was made to have the hot water within the required range.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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: APOSTOL FAMILY HOME LLC II
FACILITY NUMBER: 336425145
VISIT DATE: 02/11/2025
NARRATIVE
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (4) staff files and training. (2) of (4) staff did not have updated First aid and CPR training, and (1) of (4) staff did not have a criminal record clearance transferred to the facility roster. The facility is being cited for personnel records and a plan of correction was created. (3) client files were reviewed, and possessed all required paperwork and ledgers for personal and incident funds were accurate and up to date.

Health Related Services/ Incidental Medical Services: All client medication was locked in a staff room. LPA reviewed client medications for (3) client, based on observation and (1) staff interview (1) of (3) client PRN medications were being administered taken by staff instead of the client. The facility was cited for improper documentation and use of client PRN medication.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 11/16/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

An exit interview was conducted where this report was reviewed along with the deficiency pages and appeal rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/11/2025 03:30 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/11/2025 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APOSTOL FAMILY HOME LLC II
FACILITY NUMBER: 336425145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above with the hot water reading over 120F during the time of the visit poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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The staff agreed to adjust the hot water and send proof of a reading within the required range by the POC due date.
Type A
Section Cited
CCR
80019(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(3) Request a transfer of a criminal record clearance as specified in Section 80019(f)...This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with (1) of (4) staff who were not associated but cleared with the department which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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The staff agreed to transfer the staff to the roster and provide proof by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/11/2025 03:30 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/11/2025 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APOSTOL FAMILY HOME LLC II
FACILITY NUMBER: 336425145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85165(f)(7)
(f) The administrator who will approve the continued use of a manual restraint or seclusion shall complete additional training which shall include the following:
(7) Current first aid certification and current certification in the use of cardiopulmonary resuscitation (CPR). This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above with (2) of (4) staff not having their updated CPR and first aid training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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The staff agreed to have the (2) staff trained in CPR and send proof by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2025 03:30 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/11/2025 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APOSTOL FAMILY HOME LLC II
FACILITY NUMBER: 336425145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(6)(C)
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of…medications. (6) If the client is unable to determine his/her own need for a prescription…PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration…(C)The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with (1) staff utilizing (1) clients PRN medications for staff usage which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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The staff agreed to retrain the employees on medication administration and ethical practies of the client medications. Proof of training is due by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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