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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800173
Report Date: 04/16/2024
Date Signed: 04/16/2024 04:47:05 PM

Document Has Been Signed on 04/16/2024 04:47 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:MEGGINSON PLACE IIFACILITY NUMBER:
331800173
ADMINISTRATOR/
DIRECTOR:
RACELIS, JANETTEFACILITY TYPE:
740
ADDRESS:11330 LOMBARDY LANETELEPHONE:
(951) 363-8767
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 5DATE:
04/16/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Roberto Ducusin, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Javina George conducted an unannounced Health and Safety check at the facility. LPA was greeted and granted entry by Caregiver Ladonna Baca, and explained the purpose of the visit. At the time of LPAs visit there were two (2) staff and five (5) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. The Administrator was unable to come to the facility but was available via telephone. The facility has an approved hospice waiver for four (4) residents. The facility continues to have three (3) residents that are under hospice care.

The facility was observed to be operating within the capacity in which it was licensed for. LPA observed for staff to be preparing dinner. The gas, water and electric were operable. LPA observed for the facility food supply to meet with minimum requirements of a 2 day supply of perishable and 7 day supply of nonperishable food items.

The resident's medications were observed to be locked and inaccessible to the resident's in care. LPA spoke with Administrator via telephone to inquire about any changes at the facility with staffing, services being offered and if there have been any incidences that have occurred since the start of the new year where the facility staff had to call 911 for assistance. Per Administrator Janette there has not been any instances where emergency medical personnel assistance has been needed, and reporting requirements would be followed should the need arise.

During today's visit no health and safety concerns were observed.

An exit interview was conducted, and a copy of this report, and LIC 811 was discussed and provided to Roberto Ducusin, Caregiver.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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