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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426123
Report Date: 04/15/2024
Date Signed: 04/19/2024 03:44:38 PM

Document Has Been Signed on 04/19/2024 03:44 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:SHIRU RESIDENCES LLCFACILITY NUMBER:
336426123
ADMINISTRATOR/
DIRECTOR:		SMITH, SHIRLEYFACILITY TYPE:
735
ADDRESS:9752 VIA MONTARATELEPHONE:
(951) 206-4206
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 2CENSUS: 2DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Staff, Sean SmithTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with staff, Sean Smith who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (2) clients present.

The facility is a two story home with (5) bedrooms and (4) bathrooms for clients. No pool or firearms are present at the facility. LPA observed the following:

Infection Control: The LPA observed the hand hygiene supplies, 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: Physical plant was observed to be clean and fixtures and furniture were in good repair. LPA observed client bedrooms and bathrooms, kitchen, living areas, and out door area. No health and safety issues were observed. The hot water temperature was recorded at 120F and the carbon monoxide detector was operation during the visit.

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 food items.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SHIRU RESIDENCES LLC
FACILITY NUMBER: 336426123
VISIT DATE: 04/15/2024
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Record Review and Resident/Staff Files: LPA reviewed staff files and training, and Client files which possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a medication cabinet. Medication was accounted for on the MARS list.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility last drill was conducted on 4/13/2024.

An exit interview was conducted where a copy of this report was reviewed and provided to Staff, Sean Smith.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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