336427430-9-13-2024-18-AS-JARA-D93V2S-20240913160336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427430
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:03:43 PM

Document Has Been Signed on 09/13/2024 04:03 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:	RWINS HAVEN FOR THE ELDERLY		FACILITY NUMBER:	336427430
ADMINISTRATOR:	PERGANTIS, ANGELO		FACILITY TYPE:	740
ADDRESS:	4912 RED ROCK AVE		TELEPHONE:	(951) 525-3809
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 5	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	Licensee, Alicia Pergantis		TIME COMPLETED:	04:10 PM

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Alicia Pergantis who was informed of the purpose of the visit. At the time of the visit there was (4) staff and (5) clients present.

The facility is a one story home with (5) bedrooms, (4) for residents and (2) bathrooms with attached garage. No pools or firearms are being kept at the facility.

Infection Control: The LPA observed hygiene supplies, PPE equipment, and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients in pantry closet. The smoke detector and carbon monoxide was operational, and the hot water temperature 119.3F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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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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: RWINS HAVEN FOR THE ELDERLY	FACILITY NUMBER: 336427430
	VISIT DATE: 09/13/2024

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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (3) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in closet. LPA reviewed client medications for (2) client and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 7/1/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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