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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880693
Report Date: 06/21/2024
Date Signed: 06/21/2024 01:52:53 PM

Document Has Been Signed on 06/21/2024 01:52 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:ST FRANCIS VILLAFACILITY NUMBER:
331880693
ADMINISTRATOR/
DIRECTOR:
DANG, ANHTUANFACILITY TYPE:
740
ADDRESS:23571 RHEA DRTELEPHONE:
(714) 306-3259
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 1DATE:
06/21/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Licensee, Antuan DangTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit for the a continuation of the required annual. LPA met with Licensee, Anhtuan Dang who was informed of the purpose of the visit. During the time of the visit there was (1) staff, (1) volunteer, and (0) residents present. Resident was at their day program.

(1) staff interview was conducted during the time of the visit. LPA checked the carbon monoxide detector during the time of the visit and the hot water temperature was read at 116.9F. LPA reviewed the facility's COVID-19 plan which met the department requirements. LPA reviewed the liability insurance which is current, and the staff and client records. LPA checked (3) staff files and (1) resident file. The files had all required paperwork, criminal record clearances, and training. LPA observed the current administrator's has a valid administrator's certificate. LPA reviewed the staff schedule and observed adequate staff coverage. The client medication and MARS were reviewed. The medication administration was accounted for (1) resident.

No health and safety issues were noted at the time of the visit. No deficiencies were cited at the time of the visit. An exit interview was conducted and this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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