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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426226
Report Date: 12/07/2023
Date Signed: 12/07/2023 01:20:46 PM


Document Has Been Signed on 12/07/2023 01:20 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:BAYCARE HOUSE LLCFACILITY NUMBER:
336426226
ADMINISTRATOR:NOAH WANGAIFACILITY TYPE:
735
ADDRESS:27309 BIG HORN AVENUETELEPHONE:
(951) 306-1323
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:4CENSUS: 0DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Administrator, Noah WangaiTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with, who was informed of the purpose of the visit. At time of visit there were (0) clients and one (2) staff present.

The facility is a one story home with four (4) bedrooms and (3) bathrooms with attached garage. The facility does not have a pool or fire arms. The facility is designated an adult residential facility serving adults between the ages of 18-59 years of age. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility does not have a plan on how to mitigate infectious diseases. Technical note was documented.

Physical Plant: LPA observed the client bedrooms and bathrooms. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects had designated locked areas for storage. The smoke detector and carbon monoxide were operational, and the hot water temperature 118F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The facility did not meet the required 2-day supply of perishable and 7-day supply of non-perishable foods. Technical note was documented as there are currently no clients in care.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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: BAYCARE HOUSE LLC
FACILITY NUMBER: 336426226
VISIT DATE: 12/07/2023
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record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training. Technical note was documented for staff to recertify in CPR first aid as all staff had expired training. Technical note was also documented for administrator to send LPA health screening that was unavailable at the time of the visit. LPA provided the LIC311C for licensee to have all required files at the facility for licensing review. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: No client medications were observed at the facility. The facility has a designated place for storing medication.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA documented technical note for licensee to update the plan to new LIC610D. Technical note was also documented for facility to conduct required drills as the facility has not conducted a drill as no clients are in care. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report was provided to
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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