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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602602
Report Date: 08/14/2023
Date Signed: 08/14/2023 04:37:07 PM

Document Has Been Signed on 08/14/2023 04:37 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 HOMES, INC.FACILITY NUMBER:
374602602
ADMINISTRATOR:CHRISTINA GRUBBSFACILITY TYPE:
735
ADDRESS:405 AVALON DRIVETELEPHONE:
(760) 842-5575
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 4CENSUS: 4DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Cynthia Meyer, AdministratorTIME COMPLETED:
04:45 PM
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On 8/14/2023 Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived at the facility and was greeted by caregiver, Nancy Walters. LPA explained the reason for the visit. Administrator Cynthia Meyer arrived shortly. Two (2) staff and four (4) residents were present. 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, water and emergency supplies were stored in the garage. Hot water was measured at 107.4 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. LPA review client files and all pertinent documents were present and up to date.

P&I monies are stored in a locked safe in a locked cabinet in the entry hallway door that that is secured 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.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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 HOMES, INC.
FACILITY NUMBER: 374602602
VISIT DATE: 08/14/2023
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During the inspection, no deficiencies were observed. An exit interview was conducted and a copy of the report and LIC 811 was provided to Administrator Cynthia Meyer.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC809 (FAS) - (06/04)
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