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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800173
Report Date: 08/21/2024
Date Signed: 08/21/2024 09:25:08 AM

Document Has Been Signed on 08/21/2024 09:25 AM - 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:
08/21/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Janet Vega Racelis, Administrator TIME VISIT/
INSPECTION COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Javina George made 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 (5) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. The facility has an approved hospice waiver for four (4) residents. The facility has a total of (3) residents that are receiving hospice services.

The facility was observed to be operating within the capacity in which it was licensed for. The utilities were observed to be operable and the food supply met the requirements; of a 7 day supply of nonperishable and a 2 day supply of perishable food items. The facility has hygiene supplies, extra linen and Personal Protective Equipment (PPE) supplies. The resident's were observed in their (1 sleeping, 1 watching TV) and the facility common areas (2) watching and 1 eating breakfast. 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 unusual Injury reports received, and confirmed that there were no instances where emergency medical personnel had been contacted for assistance since the last visit was made in June 2024. LPA received an updated resident roster as well as copy of liability insurance, for the facility file at the regional office.

There were no health and safety concerns observed, during today's visit.

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: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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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