336427578-9-11-2024-18-AS-JARA-D8ZNK6-20240911103124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427578
Report Date: 09/11/2024
Date Signed: 09/11/2024 10:31:31 AM

Document Has Been Signed on 09/11/2024 10:31 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:	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:	09/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Staff, Julita Mendoza		TIME COMPLETED:	10:35 AM

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Staff, Julita Mendoza who was informed of the purpose of the visit. At the time of the visit there are no residents in the care.

The facility is a two story home with (5) bedrooms and (3) bathrooms. The upstairs is comprised of a loft area for staff use only. 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. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible. The smoke detector and carbon monoxide was operational, and the hot water temperature 105F.

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: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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: FOOTHILL LAKE HOME	FACILITY NUMBER: 336427578
	VISIT DATE: 09/11/2024

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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. No residents are residing in the home, no resident files were reviewed.

Health Related Services/ Incidental Medical Services: Resident medication will be kept in a locked cabinet.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies.

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: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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