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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881127
Report Date: 08/04/2021
Date Signed: 08/04/2021 11:52:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOME CARE FIRSTFACILITY NUMBER:
361881127
ADMINISTRATOR:ESCOBEDO, ADDYFACILITY TYPE:
740
ADDRESS:14186 CUYAMACA RDTELEPHONE:
(323) 350-2415
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:6CENSUS: 0DATE:
08/04/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Addy EscobedoTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Natalie Gayoso and Melody Brown conducted an announced pre-licensing visit to the facility. LPAs met with Administrator Addy Escobedo. The pending application is for a Resident Care Facility for the Elderly (RCFE). Currently there are 0 residents in care. Administrator accompanied LPAs on a tour of the inside and outside of the facility

The home is a three (3) bedroom, two (2) bathroom home with a living room, dining room, and kitchen. Per the approved fire clearance, the licensee is approved for 4 ambulatory and 2 non-ambulatory, of which 1 may be bedridden. The physical plant, in general, was in good repair. Buildings and grounds are free from hazards. Indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms or ammunition. All bedrooms are furnished with bed, night stand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom toilets, shower and tubs are in good repair and have grab bars and non-skid mats. LPAs measured the hot water temperature in the bathrooms. The water temperatures measured at 108 and 110 degrees F. LPAs observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. All appliances are clean and operating properly. Dishes, glasses, and utensils were in good condition. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. The backyard is completely enclosed with functioning gate to exit to front yard. Outdoor space is suitable for client use. LPAs observed fully charged fire extinguishers present in the facility. Smoke alarms and carbon monoxide detectors are present and functional. Medications are to be stored and secured in a locked cabinet inside the dining room. All hazardous materials such as, cleaning and disinfecting supplies, knives, and other sharps are locked and inaccessible to residents. The facility had a designated area for staff and resident records. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility had a supply of activities for the residents. Per Administrator laundry services will be done at the cleaners.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HOME CARE FIRST
FACILITY NUMBER: 361881127
VISIT DATE: 08/04/2021
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No corrections are need and Pre-licensing inspection is complete.

An exit interview was conducted and a copy of this report was provided to the Administrator
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC809 (FAS) - (06/04)
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