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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603354
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:14:00 PM

Document Has Been Signed on 09/07/2023 03:14 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:MAISY PLACEFACILITY NUMBER:
374603354
ADMINISTRATOR:MELANIE CUARESMAFACILITY TYPE:
735
ADDRESS:101 N UPAS STTELEPHONE:
(760) 738-6237
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 0DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Kevin Ramirez, StaffTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Cheryl Goodrich conducted an unannounced annual visit. LPA met the staff, Kevin Ramirez and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) ambulatory residents with 0 residents in care.
Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies.
Physical Plant and Environmental Safety: The facility temperature read at 73 degrees. The facility consists of four (4) resident bedrooms, and three (3) bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with lamp, closet space and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 105.6 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the hallway and inaccessible to residents. The ARF and has a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguishers and are in working order.

(Continued on LIC809-C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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: MAISY PLACE
FACILITY NUMBER: 374603354
VISIT DATE: 09/07/2023
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(Continued from LIC809)

Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service training.
Client Records-Incident Reports: The facility has no resident records due to no residents in care but has previous resident records on file.
Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has a medication logbook, however no current records are present due to no residents in care. However previous resident records were found and the facility documented the resident’s medication and is in compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 06/29/23. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Staff, Kevin Ramirez and a copy of this report was printed Signature below confirms receipt of these rights.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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