<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881004
Report Date: 05/10/2022
Date Signed: 05/11/2022 08:59:59 AM

Document Has Been Signed on 05/11/2022 08:59 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MIDTOWN VILLAFACILITY NUMBER:
331881004
ADMINISTRATOR:AGBISIT, MICHAELFACILITY TYPE:
740
ADDRESS:2789 RAFFERTY RD.TELEPHONE:
(951) 566-6610
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 102CENSUS: 0DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Dee Xu and Joanna Lee, CEOTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/10/2022, at 12:48pm Licensing Program Manager (LPM) J. Harris and Licensing Program Analyst (LPA) V. Mixson were greeted and granted entry by office staff Dee Xu. LPA Mixson introduced self and stated the purpose of the visit and was given a tour of the facility by CEO Joanna Lee and Dee-dee.

There are no residents placed at the facility at this time. There were 4 staff and no COVID positive cases. The purpose of the visit was to conduct the required annual, with the focus on infection control.

During the inspection, LPM and LPA observed that there were no sign in sheets at the front entry. There was no screening process or hand sanitizer.
The restrooms did not have liquid soap or paper towels for hand washing.
It was advised that the facility does not have an administrator. Information was provided to assist with submitting the proper documentation in order for the profile to be updated and accurate. CEO stated that the issues will be resolved prior to residents being placed at the facility. Proof of the corrections will be sent to LPA Mixson.

An exit interview was conducted and the documentation was provided to the CEO Joanna Lee.




SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1