336427578-9-21-2023-18-AS-SMAZ-CVVUW7-20230921155616

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427578
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:56:46 PM

Document Has Been Signed on 09/21/2023 03:56 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	FOOTHILL LAKE HOME		FACILITY NUMBER:	336427578
ADMINISTRATOR:	ANGELITO V. MENDOZA		FACILITY TYPE:	740
ADDRESS:	24746 MORNING MIST DRIVE		TELEPHONE:	(951) 208-1722
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY:	6	CENSUS: 0	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:43 PM
MET WITH:	Julita Mendoza - Administrator		TIME COMPLETED:	04:07 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Julita Mendoza, who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (0) resident present. The facility does not have any residents admitted due to renovations, so some items were discussed in regards to care of future residents.

The facility is a two-story home with six (6) bedrooms and three (3) bathrooms, with an attached garage. The facility does not have any bodies of water, firearms, or ammunition on the property. The residents who will be served will be elderly adults 65 years of age and older. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted an interview. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical Plant: LPA observed the resident bedrooms, bathrooms, and staff office. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature 118F.

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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FOOTHILL LAKE HOME	FACILITY NUMBER: 336427578
	VISIT DATE: 09/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Record Review and Resident/Staff Files: LPA reviewed one (1) staff file and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

Health Related Services/ Incidental Medical Services: Future resident medications will be locked in a hallway closet.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility will conduct fire and earthquake drills for staff and future residents. All facility exits were clear from obstructions. Facility had emergency supplies and first aid kit with all required items.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Julita Mendoza.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2