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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426468
Report Date: 10/13/2023
Date Signed: 10/13/2023 10:46:24 AM


Document Has Been Signed on 10/13/2023 10:46 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:FAMILYCARE HOME - MONTARAFACILITY NUMBER:
336426468
ADMINISTRATOR:JOSE KOFACILITY TYPE:
740
ADDRESS:9781 VIA MONTARATELEPHONE:
(951) 924-0181
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:4CENSUS: 3DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:ADMINISTRATOR, JOSEPH KOTIME COMPLETED:
10:55 AM
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On October 13, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection and met with the Administrator, Joseph. The LPA introduced herself, and stated the purpose of the visit.

LPA Mixson toured the facility and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single story home, located at 9781 Via Montara, Moreno Valley, CA. 92557. Physical Plant: The facility phone number is 951-924-0181, and is operable. The LPA observed the resident bedrooms, and bedrooms are equipped with required furniture as per Title 22. The LPA inspected the facility bathrooms, and the hot water temperature tested within regulations. The two bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguisher. The LPA observed required postings such as; the Ombudsman poster, "If you See Something, Say Something" and the "Personal Rights" postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents. There was a designated storage space for the resident and staff files. Medications: were reviewed, were locked, inaccessible to residents, and had a least a 30 day supply at time of the visit. The overall facility is clean, neat and organized, the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision Facility has sufficient staff, two at the time of this visit, and all residents were away at the day program. Records Review: The LPA reviewed three resident files, and three staff files. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit.
An exit interview was conducted and a copy of this report, along with the LIC 811, was given to the Administrator, Joseph Dexter.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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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