336425653-2-3-2025-18-AS-AZEO-DDK2K6-20250203162725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425653
Report Date: 02/03/2025
Date Signed: 02/03/2025 04:27:32 PM

Document Has Been Signed on 02/03/2025 04:27 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:	CROWN MANOR II		FACILITY NUMBER:	336425653
ADMINISTRATOR/ DIRECTOR:	AGNES MARTINEZ		FACILITY TYPE:	740
ADDRESS:	34153 ALBACETE AVENUE		TELEPHONE:	(951) 246-7220
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	02/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:36 PM
MET WITH:	Rommel Martinez		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by Licensee Agnes Martinez, notified her of the purpose for the visit and was allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a single story building with five (5) residents bedrooms, three(3) bathrooms, Two(2) common areas, a kitchen area and a garage. There is no gated pool and there are no firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen inaccessible to residents. The smoke detector and carbon monoxide detector were operational. LPA observed fire extinguishers to be in compliance with the department requirements and with an expiration date of February 25, 2025. The water temperature was tested within regulations measuring at 118.3 F

Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of December 29, 2025 and a CPR certification with the expiration date of August 20th, 2025

Continued 809-C......

Rikesha Stamps	TELEPHONE: (951) 212-0616
Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

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: CROWN MANOR II	FACILITY NUMBER: 336425653
	VISIT DATE: 02/03/2025

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Record Review and Resident/Staff Files: LPA reviewed files for three(3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three (3) residents' files were reviewed and contained all required documentation. LPA observed first kit to be locked and inaccessible to the residents in care. The residents and staff files were kept in a locked cabinet in the common area and inaccessible to unauthorized individuals

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the kitchen area. LPA reviewed medications for three(3) residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 1-5-2025, which met department requirements. All facility exits were clear of obstructions.

No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Licensee Agnes Martinez.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

LIC809 (FAS) - (06/04)

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