336427406-10-12-2023-18-AS-CNWE-CWJPNZ-20231012112847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427406
Report Date: 10/12/2023
Date Signed: 10/12/2023 11:28:56 AM

Document Has Been Signed on 10/12/2023 11:28 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 3		FACILITY NUMBER:	336427406
ADMINISTRATOR:	APOSTOL, JAIME C		FACILITY TYPE:	740
ADDRESS:	23609 LAKE VALLEY DRIVE		TELEPHONE:	(951) 242-9487
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92551
CAPACITY:	6	CENSUS: 4	DATE:	10/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jaime Apostol, Licensee Rosamila Apostol, Licensee		TIME COMPLETED:	11:35 AM

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On 10/12/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Eduardo Tolentino who was informed of the purpose of visit. Eduardo called Licensees, Jaime Aposto and Rosamila Apostol who arrived at the facility shortly after. At the time of visit there was 2 staff and 2 residents present. LPA also met Caregiver, Ma Lorena Emerita who toured the facility with LPA.

Tour included:

Kitchen; LPA toured the kitchen and observed food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen cabinet under the sink, available only to authorized individuals. Trash can has tight-fitting lid. Dishwasher is used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 35 degrees Fahrenheit and Freezer was measures at 0 degrees Fahrenheit.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 71 degrees Fahrenheit.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Continue on LIC809-C

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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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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: 10/12/2023

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Continue from LIC809.

Medications; LPA observed medications were labeled and stored in separate bins inside of a locked medication cabinet located in the kitchen and are distributed according to physician orders. The first aid kit was complete.

Bathroom; LPA toured hall bathroom and observed bathroom to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 105 degrees Fahrenheit.

Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. Resident #1 bedroom has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 105 degrees Fahrenheit.

Garage and Laundry; LPA tour the garage and observed garage to be clean. Washing machine and dryer are located in the garage and are all in good repair and sufficient for the census. Cleaning supplies are stored away in the garage inaccessible to clients.

Backyard; LPA toured the backyard and observed backyard to be clean. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Two #2 staff and two #2 residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expired on 5/26/2023. Jaime stated the Administrator recertification packet was mailed to the department three #3 months ago, but the certificate has not yet been received.

Interview; Two #2 staff and two #2 resident present were interviewed.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Jaime Apostol.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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