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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604137
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:23:13 PM


Document Has Been Signed on 03/15/2024 03:23 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AFFIRMATIVE'S ELITE HOMEFACILITY NUMBER:
374604137
ADMINISTRATOR:SHAH, DEENAFACILITY TYPE:
740
ADDRESS:1729 SUMMIT DRTELEPHONE:
(760) 294-0357
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Deena Shah, Administrator TIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by caregiver Luz Rivas. The Administrator Deena Shah arrived shortly after LPA, where LPA explained the purpose of the visit. The facility is licensed to serve residents that are aged 60 and over, of all which who may be non-ambulatory and there is an approved hospice waiver for 5. There are currently four (4) residents on hospice.

LPA conducted a tour of the interior and exterior of the facility and observed the following: the facility is a single story home with four (4) bedrooms and two (2) bathrooms. The facility was observed to clean, clutter free and be well manicured.

Medications were observed to be locked inside a cabinet located in the kitchen in between the refrigerator and double stacked ovens. There were no pools or bodies of water observed on the premises. There are no known guns or ammunition stored on grounds. The sharps objects such as knives are locked and are inaccessible to residents in care.

LPA observed for there to be video surveillance being utilized in the kitchen as well as the common area (living room). In addition LPA observed for there to be a camera inside a resident #1 (R1)'s bedroom. The camera was unplugged and removed at the time of LPAs visit. A technical violation was issued. LPA discussed the need for the facility sketch to be updated indicating where the camera's are placed, an addendum to the plan of operation as well as a consent for the use of video surveillance.

The emergency drills are conducted on a monthly basis, the last drill was conducted on 3/8/24. The facility recently had a detector inspection completed on 3/6/24. The fire extinguisher was checked on 10/2/23. The hot water tested in the resident bathrooms and were observed to be within regulatory limits measuring at 108.4 degrees Fahrenheit.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AFFIRMATIVE'S ELITE HOME
FACILITY NUMBER: 374604137
VISIT DATE: 03/15/2024
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The facility was observed to have a two day supply of perishable and a seven day supply of Non perishable food items. There are a total of three (3) refrigerators. In addition to 2 additional food storage pantries inside of the garage. LPA observed for the facility to have EPA approved cleaners, personal protective equipment (PPE), hygiene supplies and extra linens. The facility has games, and plenty space for the residents to enjoy and encourage socialization.

LPA conducted a records review of both staff and resident files and found to be complete with the required forms. The facility has the required postings posted throughout the facility.

Based on today's visit there were no deficiencies cited.

An exit interview was conducted and a copy of the technical violation was reviewed and provided to Deena Shah Administrator.


SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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