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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880639
Report Date: 04/19/2024
Date Signed: 04/19/2024 01:03:36 PM

Document Has Been Signed on 04/19/2024 01:03 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:WE R EVERGREENFACILITY NUMBER:
331880639
ADMINISTRATOR/
DIRECTOR:		FERRER, RUBY JOY SFACILITY TYPE:
740
ADDRESS:32969 LAMTARRA LOOPTELEPHONE:
(951) 672-6370
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 6CENSUS: 4DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Caregiver, Apollo RodellaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 4/19/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct an annual required inspection. LPA was greeted and granted entry by Caregiver, Apollo Rodella who was informed of the purpose of the visit. Licensee, Ruby Ferrer was informed of LPA's visit. During today's visit, there was four (4) residents and one (1) staff present.

The facility has a fire clearance for six (6) non-ambulatory residents ages 60 and above. The facility also has a hospice waiver for three (3) residents and LPA was informed three (3) residents are receiving hospice services at the facility. LPA toured the facility's interior and exterior with Caregiver Rodella. LPA observed the facility is made up of a one-story home with four (4) resident bedrooms, two (2) full bathrooms, three (3) living rooms, two (2) dining rooms, a kitchen, storage room, and attached garage. Indoor and outdoor passageways are free of obstruction. LPA observed the facility has more than a 2-day supply of perishable foods and 7-day supply of non-perishable foods. Caregiver Rodella tested one of the smoke alarms/carbon monoxide detectors and LPA found it to be operational. LPA observed charged fire extinguishers mounted throughout the facility. Medication is stored in a living room cabinet secured with a master lock. Disinfectants, cleaning solutions, and detergents are secured in the garage. The facility has additional linen, blankets, towels, comforters and incontinent supplies available for residents in care. LPA reviewed random resident files. Resident files reviewed have signed and updated physician reports and admission agreements. Residents rights, complaint procedures, Long Term Care Ombudsman information, and facility sketches are posted near the facility's front entrance. The facility does not safeguard the residents' cash resources. During today's visit, LPA did not observe any issues or concerns.

An exit interview was conducted and a copy of this report was reviewed and provided to Caregiver Rodella.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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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