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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427406
Report Date: 10/30/2024
Date Signed: 10/31/2024 08:21:19 AM

Document Has Been Signed on 10/31/2024 08:21 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:APOSTOL FAMILY HOME LLC 3FACILITY NUMBER:
336427406
ADMINISTRATOR/
DIRECTOR:		APOSTOL, JAIME CFACILITY TYPE:
740
ADDRESS:23609 LAKE VALLEY DRIVETELEPHONE:
(951) 242-9487
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:42 PM
MET WITH:Edelvyn TolentinoTIME VISIT/
INSPECTION COMPLETED:
06:35 PM
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Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Armando Perez conducted an unannounced visit for a required annual inspection. The LPAs were greeted by the caregiver Edelvyn Tolentino, notified him of the purpose for the visit and were allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a single story building with 4 residents bedrooms, 2 bathrooms, 1 staff room, a living room and dining room, an enclosed patio and a garage. There is no gated pool and there are no firearms on the premises.

Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in a cabinet under the sink and inaccessible to residents. The smoke detector and carbon monoxide detector were wired together and were operational. LPAs observed fire extinguishers to be in compliance with the department requirements and with an expiration date of 06/28/2025. LPAs observed the hot water temperature to meet requirements at 109.7°F. LPAs observed an enclosed patio to have a bed for staff. A citation will be given. LPAs observed an empty pond with a diameter of three(3) feet and dept of one and half (1.5) feet. Facility will be cited

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.


Continued on LIC809-C.....
Rikesha StampsTELEPHONE: (951) 212-0616
Abdoulaye ZerboTELEPHONE: (951) 248-2222
DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: APOSTOL FAMILY HOME LLC 3
FACILITY NUMBER: 336427406
VISIT DATE: 10/30/2024
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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator/licensee holds a current administrator’s certificate with expiration date of May 18th, 2025 and a CPR certification with the expiration date of January 18, 2026

Record Review and Resident/Staff Files: LPAs reviewed files for four(4) staff members confirming criminal clearances, updated training, and CPR/First Aid certification. Four(4) residents' files were reviewed and contained all required documentation. LPAs observed Staff and resident files, to be stored in a in a locked staff room. The first aid kit was stored in a cabinet in the kitchen area.


Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the kitchen area. LPAs reviewed medications for four (4) residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on September 20,2024, which met department requirements. All facility exits were clear of obstructions.


Two(2) deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Rosamila Apostol along with the appeal letter.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye ZerboTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/31/2024 08:21 AM - It Cannot Be Edited

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: APOSTOL FAMILY HOME LLC 3
FACILITY NUMBER: 336427406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87307(e)

87307
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of one empty pond, one and half feet deep, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee agreed to put a plant in the pond and send proof of completion by the POC due date.
Type B
Section Cited
HSC
87307(a)
87307
Personal Accommodations and Services

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of one bed observed in a common area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee agreed to remove the bed designated for staff, and make the coverved patio a common area. Proof will be sent to LPA by the POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye ZerboTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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