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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881399
Report Date: 06/07/2024
Date Signed: 06/11/2024 10:02:01 AM

Document Has Been Signed on 06/11/2024 10:02 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:HOPE ARFFACILITY NUMBER:
371881399
ADMINISTRATOR/
DIRECTOR:
DOST, LEENAFACILITY TYPE:
735
ADDRESS:551 VIA DEL CABALLOTELEPHONE:
(760) 877-5773
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY: 4CENSUS: 0DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Leena Dost, Administrator TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA George met with Administrator Leena Dost and informed her of the purpose of today's visit. Below is a summary of what was observed during today’s inspection: At the time of the visit there was one (1) staff and zero (0) client's present. The Licensee/Administrator is currently undergoing the vendorization process with the placing agency. The appointment has been scheduled for July 16, 2024.

Physical Plant: LPA conducted a tour of the interior and exterior of the facility and observed for the facility to be clean and clutter free. The client bedrooms The exits, and passageways were observed to be free from obstruction. There are no pools or bodies of water on the premises.

Records Review: The facility currently has one staff that has obtained proper criminal record clearance and was associated to the facility. Staff present at have current CPR/First Aid Certification. There were no client records reviewed as there are no clients currently residing at the facility.

Food Services: the facility was observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items.



Medication: Resident medication will be locked in a cabinet next to the sliding glass door. No medications were reviewed during today's visit.
Emergency Disaster Preparedness: The smoke and carbon monoxide detectors were tested and were found to be operable. The facility has two (2) fully charged fire extinguishers. There are no known guns or ammunition on the premises. The hot water was tested and was found to be within regulatory limits.
An exit interview was conducted and a copy of this report, were provided to Administrator Leena Dost.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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