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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600388
Report Date: 06/24/2023
Date Signed: 06/24/2023 02:58:27 PM

Document Has Been Signed on 06/24/2023 02:58 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HEARTS OF GOLD CARE HOMEFACILITY NUMBER:
374600388
ADMINISTRATOR:ASTRID BRUNETFACILITY TYPE:
735
ADDRESS:2856 FOOTHILLTELEPHONE:
(760) 599-0079
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 6DATE:
06/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Cynthia Meyer, AdministratorTIME COMPLETED:
03:00 PM
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On 6/16/23, at 11:15am License Program Analyst Jacqueline Shaw Ross attempted to make an unannounced required annual visit to this facility. Upon arrival the LPA rang the front doorbell and knocked at the door several times. No person responded and it appears no person was present. LPA called Licensee and left a voicemail. The LPA will return on a later date to complete this visit.

On 6/24/2023 at 10:45am, LPA Shaw Ross arrived at the facility and was greeted by Facility Coordinator, Miguel Flores. LPA explained the reason for the visit. Facility Liaison Zoe Wilson and Administrator Cynthia Meyer arrived shortly. No other staff nor clients were present. LPA was informed all six (6) clients were on an outing. A tour was conducted of the facility inside and out.

The facility is a one story four (4) bedroom, three (3) bathroom home. The facility appears clean and free of odors. Resident bedrooms are clean and appropriately furnished. All smoke and carbon monoxide detectors were tested and found operable. Food supplies are sufficient. Emergency food and water was stored in the garage. Hot water was measured at 107.8 degrees Fahrenheit in the residents bathroom. LPA observed all toxic chemicals and other hazards secured and inaccessible to residents and are centrally stored in a locked cabinet in the kitchen. Furniture in the facility is in good repair. Outdoor space is free of hazards.

LPA inspected staff and client records. Review of staff records indicated all staff have criminal record clearances and are appropriately associated to the facility. Staff files had the required documentation including First Aid Certifications and training documents.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HEARTS OF GOLD CARE HOME
FACILITY NUMBER: 374600388
VISIT DATE: 06/24/2023
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P&I monies are stored in a locked safe in the office and are maintained separately from facility funds. LPA inspected medications and medications appear to be dispensed appropriately according to physician's orders. The facility is completing emergency drills on a monthly basis. Dues are current.

During the inspection, no deficiencies were observed. An exit interview was conducted and a copy of the report and LIC 811 was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023
LIC809 (FAS) - (06/04)
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