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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881383
Report Date: 01/15/2025
Date Signed: 01/15/2025 11:20:14 AM

Document Has Been Signed on 01/15/2025 11:20 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOOD SAMARITAN ELDERLY HOME IIFACILITY NUMBER:
331881383
ADMINISTRATOR/
DIRECTOR:		CARREON, MELDY AFACILITY TYPE:
740
ADDRESS:12145 WESTERLY TRAILTELEPHONE:
(951) 259-4762
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 4DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Mimichaela Carpio-Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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 Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Direct Support Caregiver Mimichaela Carpio who was informed of the purpose of the visit. The facility has a fire clearance for six (6) Non-Ambulatory and a Hospice waiver approved for two (2).

LPA toured the facility with Direct Support Caregiver and reviewed records. During the tour, LPA observed the facility is made up of a one (1) story home with three (3) resident bedrooms, one (1) staff room, one (1) resident bathroom and one (1) staff bathroom, a living room, dining room, kitchen and attached garage. Facility has a Activity room located next to the dining area where LPA observed activity games, computers and arts and craft. All resident's bedrooms had required furniture and lighting. LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. Outdoor shaded seating area is also available for the residents in care. LPA observed a hallway cabinet filled with clean towels, blankets, and linen, available for the residents. LPA toured the kitchen and observed the facility has a 2-day supply of perishable foods and more than a 7-day supply of non-perishable foods, which are stored in a safe and healthful manner. LPA observed that sharp knives and dish washer supplies are located in a locked kitchen cabinets. Resident's medications are also locked in the kitchen cabinet. LPA toured the garage and observed that there are multiple cabinets that have extra bedding sets and clean linen sheets available for the residents. LPA observed that the garage has the Emergency kits and supplies stored in a cabinet. LPA observed that the laundry room had cleaning solutions, laundry detergent, and disinfectants in a locked cabinet. Direct Support Caregiver Mimichaela tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed two (2) charged fire extinguishers mounted throughout the facility, last serviced on 12/4/24. Exit signs, emergency contact information, resident's personal rights, and complaint information are visibly posted near the entrance and throughout the facility.
During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided.


SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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