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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 03:27:42 PM

Document Has Been Signed on 06/20/2024 03:27 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:Case Management - Health ChecksUNANNOUNCEDTIME 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 Health and Safety check at the facility. LPA was greeted and granted entry by Administrator, Janette Vega Racelis and explained the purpose of the visit. At the time of the visit there were two (2) staff and five (4) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. Both staff are licensee and have administrator's certificates. The facility has an approved hospice waiver for four (4) residents. The facility now has two (2) residents that are under hospice care. A resident on hospice care passed away on June 12, 2024. LPA obtained the incident report, reviewed resident documents, and interviewed staff.

The facility was observed to be operating within the capacity in which it was licensed for. The utilities were operating and facility food meet the department requirements. The facility has hygiene supplies and PPE supplies. The facility resident were observed in their rooms and the facility common areas. The resident's medications, cleaning supplies and sharps were locked and inaccessible residents. LPA spoke with administrator any incidences that have occurred since the last department visit where they 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.
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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