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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426343
Report Date: 08/03/2023
Date Signed: 08/03/2023 09:36:45 AM

Document Has Been Signed on 08/03/2023 09:36 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAU ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
336426343
ADMINISTRATOR:JEFFREY GOMEZFACILITY TYPE:
735
ADDRESS:7665 DUFFERIN AVE.TELEPHONE:
(909) 342-8379
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 6CENSUS: 3DATE:
08/03/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Direct Support Person (DSP), Richard Ratcliffe TIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with Direct Support Program, Richard Ratcliffe. LPA was informed that three (3) residents currently reside at this facility. There were two (2) staff on duty during the time of the visit. There were two (2) residents at the facility during the time of the inspection.

LPA toured the facility and observed all facility utilities to be on and operating without issues, food supply is sufficient, there is no immediate concern for residents in care. During the facility plant and environment tour, LPA observed the A/C to be leaking. The facility had put pads to cover the floors and a bucket to catch the leaking water. LPA spoke to the Administrator, Jeffrey Gomez, on the phone and the Administrator stated that he will have it fixed by August 14th, 2023. Administrator stated that he will send proof of the A/C being fixed to the LPA. A technical advisory per HSC 80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with DSP, Richard Ratcliffe and a copy of this report is left with the Richard Ratcliffe as evidence by his signature.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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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