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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530196
Report Date: 03/07/2024
Date Signed: 03/07/2024 10:22:41 AM


Document Has Been Signed on 03/07/2024 10:22 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:TREE OF LIFE CARE HOMEFACILITY NUMBER:
365530196
ADMINISTRATOR:RAJPOOT, BILALFACILITY TYPE:
740
ADDRESS:1652 VIA SEVILLA STTELEPHONE:
(714) 883-3303
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:6CENSUS: 0DATE:
03/07/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Bilal Rajpoot- AdministratorTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Ryan Gardner conducted an announced visit to complete the Pre-licensing inspection. LPA met with Administrator Bilal Rajpoot for a Residential Care Facility for the Elderly (RCFE) for six (6) non-ambulatory residents, one (1) resident may be bedridden. The fire clearance was approved by the fire department on 1/23/2024.

The facility has four (4) bedrooms and three (3) bathrooms. There are three (3) resident bedrooms, one (1) staff bedroom, a kitchen, a living room, two (2) dining areas, a laundry room, a backyard, and an attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected:

Resident Bedrooms: All bedrooms have the required bedding and furniture, such as clean mattresses/linens, mattress covers, nightstands, dressers, chairs, and lighting.

Resident Bathrooms: The bathrooms appliances were operating in safe and sanitary condition. The water temperature was measured by LPA, the thermometer read at 113.7 degrees F.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for resident use. The kitchen appliances and countertops were free of debris and in good repair. The refrigerator was measured at 40 degrees F and the freezer was measured at 0 degrees F. The sharps were locked in the kitchen cabinet.

Medication: The medications will be locked in the kitchen cabinet.

Common Sitting Areas/Activities: There is adequate seating in the common areas for the residents. The facility has a supply of activities for the residents.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TREE OF LIFE CARE HOME
FACILITY NUMBER: 365530196
VISIT DATE: 03/07/2024
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Laundry Room/Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available for each resident. The laundry room contains chemicals that were locked underneath the sink.

Backyard: There are no bodies of water in the backyard. There is a covered area with seating for the all the residents. All passageways were free from obstruction.



Fire extinguisher, carbon monoxide, firearms: There are two (2) charged fire extinguishers in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and or ammunition.

Postings: LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, labor laws, and personal rights.

First aid and working telephone: The facility is equipped with a complete first aid kit and manual. The facility has a working telephone for resident use.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and the facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

The required Comp III presentation was completed. An exit interview was conducted, and this report was discussed and provided to Administrator Bilal Rajpoot.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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