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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604219
Report Date: 08/23/2023
Date Signed: 08/24/2023 02:14:23 PM

Document Has Been Signed on 08/24/2023 02:14 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:REAL HOMEFACILITY NUMBER:
374604219
ADMINISTRATOR:QUITEVIS, JHODEEFACILITY TYPE:
734
ADDRESS:2281 RITTER PLACETELEPHONE:
(650) 238-4987
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 5CENSUS: 3DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Jhodee QuitevisTIME COMPLETED:
11:30 AM
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On 08/23/23 at 8:26 a.m. Licensing Program Analyst (LPA) Cheryl Goodrich arrived to conduct an unannounced annual visit. LPA met with the caregiver Marvyn Ban-Eg (RN) at the front door and was granted entry. Administrator Jhodee Quitevis arrived during the visit. 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 five (5) non-ambulatory residents.
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, cleaning supplies, protective eye equipment.
Physical Plant and Environmental Safety: There are a total of 5 resident bedrooms, and two bathrooms, a kitchen, living room, office area, backyard area with furniture for residents and staff, and a transportation vehicle. All rooms, Living room, office area, kitchen and dinning room are all clean and clear of obstruction. The resident bedrooms were clean and clear from obstruction. The resident’s rooms were complete with Hoyer for lifting the residents and clean linens and bedding, a television, dresser, table lamp and closet space.
Operational Requirements: The facility was staffed with 5 caregivers and 1 respiratory therapist. The facility meets the operational requirements for an ARFPSHN and has a current fire clearance for the facility.
Personnel Records-Training: All have fingerprint clearances, current CPR/First Aid certification, Health screen and a TB test completed. All staff complete monthly in-service training and fire-drills and disaster training.

(Continued on LIC809-C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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: REAL HOME
FACILITY NUMBER: 374604219
VISIT DATE: 08/23/2023
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(Continued from LIC809)

Client Records-Incident Reports: The resident records are complete with pre-assessments, physician reports, admissions agreements, physician reports and orders, medication log, daily logs of the resident’s health condition, and additional medical assessments.
Client Rights-Information: The resident’s right documentation is present. The resident records also contain needs assessment information for each resident.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents.
Health- Related Services: The caregivers at the facility are dispensing medications within the guidelines of the physician’s order and the regulations. The facility is documenting the date and time of the dispensing of medication for each resident.
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 07/29/23. 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 Administrator Jhodee Quitevis 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: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
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