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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881133
Report Date: 09/30/2021
Date Signed: 09/30/2021 05:36:53 PM

Document Has Been Signed on 09/30/2021 05:36 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:PLATINUM LIVING, LLCFACILITY NUMBER:
331881133
ADMINISTRATOR:GUARING, MIRAFE IRISH DFACILITY TYPE:
740
ADDRESS:14949 EDELWEISS PLACETELEPHONE:
(951) 353-5331
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 6DATE:
09/30/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Mirafe Guaring, AdministratorTIME COMPLETED:
05:50 PM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation for Change of Ownership. At approximately 3:20 PM, LPA met with Administrator Mirafe Guaring. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 2/1/2021 for a total capacity of five (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 05/3/2021. LPA Delgado observed the following:
Structure:
Facility was a one-story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom #1, #2, #3 will accommodate any non-ambulatory resident, bedroom #4 will accommodate bedridden resident. 4 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 3:46 PM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured between 76.5-104.5 degrees Fahrenheit for sinks and shower faucets.
(CONTINUED ON LIC809C)
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PLATINUM LIVING, LLC
FACILITY NUMBER: 331881133
VISIT DATE: 09/30/2021
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(CONTINUED FROM LIC 809)
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located in the garage. Laundry detergents and cleaning supplies were observed in garage secured in a locked cabinet away from residents.
Living/Family room:
There was a living/family room with inadequate seating for all clients.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence and hygiene supplies stored in the garage..
Yards/Outside:
Patio furniture for outdoor seating is arrange and has a wooded overhead patio attached to the structure of the facility. There was a gate on the left side of the property with a self-latching hook from the exterior door. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main living room. There was Ombudsman poster and Let-Us-No poster observed.
General items:
One (1) fire extinguisher were charged and located in the kitchen. Seven (7) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the living room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was observed however the required 72-hour emergency food supply was minimal. Component III was not completed during the inspection. Component III will be scheduled for 10/1/2021 via ZOOM..
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PLATINUM LIVING, LLC
FACILITY NUMBER: 331881133
VISIT DATE: 09/30/2021
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(CONTINUED FROM LIC809C)
Pre-Licensing is incomplete and the following deficiencies to be resolved by 10/4/2021:
obtain additional 72-hour emergency food supply
obtain walkie talkies for emergency disaster plan
repair kitchen sink cabinet right side door
replace trash cans in bathroom and bedrooms with lidded trash cans
repair and obtain water temperature needs to be adjusted between 106 degrees and 120 degrees



A follow up Pre-Licensure LIC809 will be generated upon resolution of deficiencies.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC809 (FAS) - (06/04)
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