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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425342
Report Date: 01/06/2025
Date Signed: 01/06/2025 03:55:55 PM

Document Has Been Signed on 01/06/2025 03:55 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:MENIFEE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
336425342
ADMINISTRATOR/
DIRECTOR:		SENGAMPHAN, ARLEENFACILITY TYPE:
735
ADDRESS:30927 GREEN BRANCH ST.TELEPHONE:
(951) 301-5525
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 4DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Arleen Sengamphan - Administrator TIME VISIT/
INSPECTION COMPLETED:
04:18 PM
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Licensing Program Analyst (LPA) Ferrer Sabarias conducted an unannounced annual visit. Upon arrival, LPA was granted entry and met with and the Administrator Arleen Sengamphan who was informed of the purpose of the visit. At the time of the inspection, there was one (1) staff member and one (1) client present.

The facility is a two-story home with six bedrooms and three bathrooms, complete with an attached garage. No pools or other bodies of water was observed on the property, according to Administrator no firearms or dangerous weapons are stored at the facility.



During the inspection, LPA observed the hand washing stations in the facility restrooms and kitchen, which were equipped with hand hygiene supplies. Additionally, LPA observed the presence of personal protective equipment (PPE) and cleaning supplies for regular facility maintenance. LPA reviewed the facility’s infection control plan, which met department requirements. LPA reviewed staff records and clients records.

LPA inspected the client and staff bedrooms. The physical plant, including floors, windows, and doors, were found to be clean. Fixtures and furniture were well maintained. outdoor area was hazard-free, with outdoor furniture and a shaded space for clients. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to clients. Smoke and carbon monoxide detectors were observed to be operational, and the hot water temperature was set to 112.4°F. Three fire extinguishers are current with an inspection of 12/3/2024.

Continue on LIC809C...

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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: MENIFEE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 336425342
VISIT DATE: 01/06/2025
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Continued from LIC809…

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 two (2) day supply of perishable and seven (7) day supply of non-perishable foods.

LPA also reviewed the staff schedules showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator has a pending administrator Certificate.

All client’s medication are locked in a cabinet located in the hallway area. LPA reviewed medications for three (3) clients and found all medication listed on MAR and all required labeling was found to be in place.



LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs monthly fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed first aid kit with all required items.

An exit interview was conducted where a copy of this report was provided to Administrator Sengamphan.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC809 (FAS) - (06/04)
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