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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800464
Report Date: 03/24/2025
Date Signed: 03/24/2025 11:05:27 AM

Document Has Been Signed on 03/24/2025 11:05 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:MASHBURN HOMES INCFACILITY NUMBER:
331800464
ADMINISTRATOR/
DIRECTOR:		MARIAN BUNDALIANFACILITY TYPE:
740
ADDRESS:853 PIKE DRTELEPHONE:
(951) 927-0611
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 5CENSUS: 4DATE:
03/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Administrator Christopher BundalianTIME VISIT/
INSPECTION COMPLETED:
11:13 AM
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Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with administrator, Christopher Bundalian. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of three (3) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. Water temperature measured within requirements. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in hallway room. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home and no bodies of water observed.

LPA began review of client records. Four (4) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. During record review, LPA observed clients to be associated with Inland Regional Center. LPA reviewed IPP and P&I logs to be available. LPA observed client records to be available and complete.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Armando Perez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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: MASHBURN HOMES INC
FACILITY NUMBER: 331800464
VISIT DATE: 03/24/2025
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LPA conducted review of employee records. Four (4) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 08/11/2025. LPA observed personnel records to be available and complete.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen under the sink.

Medications are centrally stored. There is a locked cabinet in the hallway allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.



P&I was reviewed. LPA observed that the facility maintains a separate log for each individuals’ monies. Money counted count was accurately reflected on the ledger.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers was last serviced on 12/06/2024. Fire drills are conducted monthly at the facility with the last drill on 02/08/2025.



Based on the information received during this visit today in the areas reviewed, there are no deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809 report was reviewed with the facility representative and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Armando Perez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
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