336425913-8-29-2024-18-AS-VMIN-D8LPW5-20240829114010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425913
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:40:18 AM

Document Has Been Signed on 08/29/2024 11:40 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CITIVIEW RESIDENTIAL CARE		FACILITY NUMBER:	336425913
ADMINISTRATOR:	EMIA, VIMINDA		FACILITY TYPE:	740
ADDRESS:	15646 RANCHO VIEJO DRIVE		TELEPHONE:	(951) 780-1288
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	6	CENSUS: 6	DATE:	08/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	ADMINISTRATOR, JENELYN TAMAYOR		TIME COMPLETED:	11:45 AM

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On August 29, 2024, Licensing Program Analyst (LPA), Venus Mixson, made an unannounced visit to the facility for the purpose of conducting the Required Annual inspection, and met with Jenelyn Tamayor,Administrator, introduced herself and stated the purpose for the visit.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.

PHYSICAL PLANT: Facility is licensed for 6 elderly adults and is operating at 100% capacity which is within the conditions and limitations of the license. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to staff, there are no known weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. Temperature was within in regulations for this time of day and the season. There was sufficient lighting throughout the facility and the Hot water tested within regulations at 105.5 degrees F. Fire extinguisher located in kitchen area has proper inspection tag. The smoke and carbon monoxide alarms were in the green and last inspected on June 2024, by the Fire department. The interior and exterior areas of the home were observed to be clean and organized.

FOOD SERVICE: There was a variety of food types which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean. LPA observed the required two-day supply of perishable and seven-day supply of non-perishable foods.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITIVIEW RESIDENTIAL CARE	FACILITY NUMBER: 336425913
	VISIT DATE: 08/29/2024

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Care & Supervision/Administration: Adequate staffs are present for the supervision of residents in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses an administrator certificate and it is current.

Record Review and Resident/Staff Files: LPA reviewed two staff files and reviewed the facility's staff schedule. All staff have criminal clearance and updated training along with CPR/First Aid Certification, five resident files were reviewed and possessed all required paperwork.

MEDICATION: Medications were reviewed, and medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care. Medications and medication documentation was observed to be organized and maintained.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards and was conducted in June of 2024.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at the time of this visit.

An exit interview was conducted where a copy of this report was discussed and given to the Administrator, Jenelyn Tamayor.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC809 (FAS) - (06/04)

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