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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426772
Report Date: 04/08/2024
Date Signed: 04/08/2024 02:38:36 PM


Document Has Been Signed on 04/08/2024 02:38 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: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:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Caregiver, Adela FetalvoTIME COMPLETED:
02:45 PM
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On 4/8/2024, Licensing Program Analyst, (LPA) Janette Romero arrived unannounced to conduct an annual required inspection at the facility. LPA met with Caregiver, Adela Fetalvo who was informed of the purpose of the visit. During the visit, there was six (6) residents and two (2) staff present. The facility has a fire clearance for five (5) non-ambulatory residents and one (1) bedridden resident. The facility has an approved hospice waiver for four (4) residents and LPA was informed there are currently two (2) residents receiving hospice services at the facility.

LPA toured the facility's interior and exterior with Caregiver Fetalvo. During the tour, LPA observed the home is clean and furniture is in good repair. LPA observed residents watching television in the living room and sleeping in their rooms. Complaint procedures are posted in the living room. Caregiver Fetalvo tested the smoke alarm/carbon monoxide detectors and LPA observed them to be operational. Indoor and outdoor passageways are free of obstruction. LPA toured the kitchen and observed the facility has more than a 2-day supply of perishable food items and 7-day supply of non-perishable food items. The fireplace in the dining room is adequately screened. Resident bedrooms have the required bedding, furniture and lighting. Resident bathrooms had non-skid mats in the showers. LPA reviewed random staff and resident files. Staff files have the Department's required training records, a criminal record clearance on file and valid first aid certification. Resident files have signed admission agreements and updated physician's reports. Medications are secured in a kitchen cabinet and disinfectants are secured in the garage. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Caregiver Fetalvo.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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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