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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881284
Report Date: 04/05/2022
Date Signed: 04/05/2022 04:28:50 PM


Document Has Been Signed on 04/05/2022 04:28 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:KWIK ELDERLY ESTATEFACILITY NUMBER:
361881284
ADMINISTRATOR:ZEBEDEUS, MOODYFACILITY TYPE:
740
ADDRESS:25615 STATE STREETTELEPHONE:
(909) 492-1609
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 5DATE:
04/05/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Moody Zebedeus, LicenseeTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Anna Bueno and Rayshaun Nickolas conducted an announced pre-licensing inspection. LPAs met with Licensee and Administrator, Moody Zebedues. This pre-licensing inspection is for a change of ownership application with five (5) residents in care. The fire clearance was approved on 3/21/2022 for six (6) non ambulatory residents.

The residence is a four (4) bedroom, two (2) bath home with an attached garage. All necessary postings were observed. All bedrooms are furnished with a bed, night stand, dresser and chair. Bedrooms have adequate lighting for residents’ use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The water temperature was tested and observed to be between 111-114 degrees Fahrenheit. The smoke and carbon monoxide alarms were tested and are in operating order. Fire extinguishers are present in the facility and fully charged. The kitchen was observed to have dishes, silverware, pots, and pans. Knives are locked in a cabinet in the kitchen area. Staff and resident files and medications were locked in a cabinet in the office area. A complete first aid kit was observed to be complete. The chemicals were locked in a cabinet under the sink. The backyard was observed to be fully fenced with an unlocked gate and has a shaded patio area with table and chairs for client’s comfort while sitting outside.

An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Moody Zebedues.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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