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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426772
Report Date: 12/22/2021
Date Signed: 12/22/2021 02:59:40 PM

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:AILIDA RETIREMENT HOMEFACILITY NUMBER:
336426772
ADMINISTRATOR:ANNALISA OLIVAN-BLANCAFLORFACILITY TYPE:
740
ADDRESS:38124 AUGUSTA DRIVETELEPHONE:
(951) 696-2482
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
12/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Annalisa Blancaflor, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct a health and safety check following receipt of a report the facility had limited staffing. The LPA met with Administrator, Annalisa Blancaflor, and informed her of the purpose of this visit.

On this date the LPA conducted staff/resident interviews, reviewed records, took copies of pertinent documentation, and toured the facility. Only Two (2) staff were observed present at the facility on this date, however, one additional sleeping area was observed in the staff living quarters. There are currently six (6) residents in care. According to the Administrator, only two (2) staff are presently working at this time, while an additional staff member works part-time. Additional interviews could not provide a definitive answer as to how many staff are working in the home. An interview was attempted with Staff One (S1), however, the individual could not answer the LPA's questions due to a language barrier. Resident interviews could not indicate whether S1's lack of ability to communicate with residents has affected their health and safety needs or not.

No current health and safety threats were observed at this time. This report was reviewed with the Administrator and a copy provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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