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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880763
Report Date: 08/17/2021
Date Signed: 09/21/2021 04:38:21 PM

Document Has Been Signed on 09/21/2021 04:38 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NEW HOPE RESIDENTIAL ELDER CARE IIIFACILITY NUMBER:
331880763
ADMINISTRATOR:MIKENAS, ANNIE JANE ZFACILITY TYPE:
740
ADDRESS:36040 PEPPERDINE COURTTELEPHONE:
(951) 599-4585
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 4DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jane MikenaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual inspection. LPA Prieto met with Jane Mikena .The home is licensed for 6 bedridden residents with six hospice. There are four clients at the facility at the time of visit.

The home is a five (5) bedroom, three (3) bath home with a living room, dining room and kitchen. All bedrooms are furnished with bed, night stand, dresser and chair. Bedrooms have adequate lighting for residents’ use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The kitchen was observed clean and orderly. The chemicals are locked and kept in a separate area. The backyard was observed to be fully fenced with an unlocked gate and has shaded area with table and chairs for client’s comfort while sitting outside.

During the visit LPA discussed infection control procedures and practices with Ms Mikena. The home appeared to be in compliance and no deficiencies were observed or cited.

An exit interview was conducted and a copy of this report was reviewed with and provided to Ms Mikena.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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