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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881204
Report Date: 12/20/2021
Date Signed: 12/20/2021 11:14:18 AM

Document Has Been Signed on 12/20/2021 11:14 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PITACHE RESIDENTIALFACILITY NUMBER:
361881204
ADMINISTRATOR:WILLIAMS, NATALIEFACILITY TYPE:
735
ADDRESS:18025 PITACHE ST.TELEPHONE:
(909) 671-2812
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 0DATE:
12/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Diana BecerrilTIME COMPLETED:
11:25 AM
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Licensing Program Analysts (LPAs) Anna Bueno and Bernadette Allen conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a Adult Residential Facility was submitted to the Central Applications Unit (CAU) on 9/21/2021 for a total capacity of 4 non-ambulatory. Fire Clearance was granted 11/04/2021. LPA Bueno and Allen observed the following:

Structure: Facility was a single-story house with four (3) resident bedrooms, two bathrooms, living room, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: Each resident bedroom will accommodate non-ambulatory only clients. All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by applicant and thermometer read by LPA at 119 F.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.

Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Linens and Hygiene Supplies: An adequate supply of linens was available.

Yards/Outside: The covered patio area was not included in the facility sketch.. There were no bodies of water observed anywhere on the property.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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 10
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: PITACHE RESIDENTIAL
FACILITY NUMBER: 361881204
VISIT DATE: 12/20/2021
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Garage: Laundry area with washer and dryer were located in the garage. Laundry detergents and cleaning solutions were not secured. Garage was organized and free of obstructions. There was a recreational leisure area set up for staff and client use.

Emergency phone numbers and Exit Plan: Let-Us-No poster, Ombudsman poster and clients rights were not posted.

General items: The facility has 5 smoke alarms and 1 carbon monoxide detectors. These were tested and operational.

Technical Advisories and corrections will need to completed before the facility can be licensed.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC809 (FAS) - (06/04)
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