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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425204
Report Date: 04/12/2024
Date Signed: 04/12/2024 10:21:21 AM


Document Has Been Signed on 04/12/2024 10:21 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:TEMPLE PARK LIVINGFACILITY NUMBER:
336425204
ADMINISTRATOR:ESTA HOBBSFACILITY TYPE:
740
ADDRESS:40112 TENNYSON RD.TELEPHONE:
(951) 239-1557
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Anna HornTIME COMPLETED:
10:30 AM
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On 4/12/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct a required annual inspection. LPA met with Caregiver, Anna Horn who was informed of the purpose of the visit. LPA spoke with Administrator, Esta Hobbs over the phone and explained the purpose of the visit. The facility has fire clearance to care for six (6) non-ambulatory residents ages 60 and above. The facility also has an approved hospice waiver for six (6) residents and LPA was informed there are currently three (3) residents receiving hospice services at the facility.

During today's visit, LPA conducted a tour of the facility with Caregiver Horn. During the tour, LPA observed the facility is made up of five (5) resident rooms, three (3) bathrooms, a kitchen, living and dining room, and attached garage. LPA observed residents in their rooms and in common areas. LPA toured the kitchen and observed the facility has more than a 2-day supply of perishable foods and 7-day day supply of non-perishable foods. LPA observed smoke alarms/carbon monoxide detectors present at the facility. LPA also observed fire extinguishers charged and mounted throughout the facility, serviced on 4/4/2024. Indoor and outdoor passageways are free of obstruction. Resident rooms have the required bedding, furniture, and functional lighting. Resident bathrooms were equipped with grab bars. The facility has additional linen and towels stored in a hallway closet. Cleaning solutions and disinfectants are secured in a locked cabinet under the kitchen sink. Medications are secured in a separate locked kitchen cabinet. Facility sketch and license, personal rights poster and Long Term Care Ombudsman information were posted near the facility entrance.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and this report was reviewed and provided to Caregiver Horn.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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