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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881303
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:37:42 PM

Document Has Been Signed on 07/14/2022 03:37 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:REGENCY RANCH CARE HOMEFACILITY NUMBER:
331881303
ADMINISTRATOR:CALMA, MARICELFACILITY TYPE:
740
ADDRESS:16005 REGENCY RANCH RDTELEPHONE:
(951) 776-3289
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 6CENSUS: 4DATE:
07/14/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maricel Calma, ApplicantTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced pre-licensing inspection to the facility. The LPA met with Applicant, Maricel Calma. There are currently four (4) residents in care due to a change of ownership.

Application: The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for six (6) non-ambulatory residents, of which one (1) may be bedridden.

Buildings and Grounds: The home is composed of five (5) bedrooms, three (3) bathrooms, a laundry room, two living room areas, kitchen and two (2) dinning areas, front/back yard areas and two (2) garage spaces. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Calma, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished and privacy is available. The dining and living room areas/furniture are clutter free and in good condition. Bathrooms were observed to have non-slip mats available. The hot water was tested and measured at 104.5 degrees Fahrenheit, not within regulatory limits. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order.

Storage and Supplies: Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away under the kitchen sick and in the garage, inaccessible. Linens, and equipment are all in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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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: REGENCY RANCH CARE HOME
FACILITY NUMBER: 331881303
VISIT DATE: 07/14/2022
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are in working order. Sharps will be stored in a locked kitchen drawer, available only to authorized individuals.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights, rights of resident council, a Facility Sketch (LIC 999), Labor Law Information, and Complaint Information.

The following was observed to require correction: Hot water tested in hall bathroom (resident's bathroom) and measured at 104.5.

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure once proof of corrections are received from the applicant by 07/15/22. This report was discussed with and a copy provided to Calma.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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