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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800173
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:28:37 PM

Document Has Been Signed on 06/20/2024 03:28 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: 4DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Administrator, Janette Vega RacelisTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Janette Vega Racelis, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (4) clients present.

The facility is a one story home with (7) bedrooms and (4) bathrooms with attached garage. (2) bedrooms are for staff, and (1) bathroom is for staff. (1) of the (5) resident rooms are shared. The facility is approved for bedridden status in room #3 and is approved for (4) hospice residents. No pools or firearms are being kept at the facility. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide alarms were operational, and the hot water temperature 116F
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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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: MEGGINSON PLACE II
FACILITY NUMBER: 331800173
VISIT DATE: 06/20/2024
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Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a closet. LPA reviewed client medications for (2) client and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill March 2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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