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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881410
Report Date: 05/24/2023
Date Signed: 06/12/2023 09:18:53 AM

Document Has Been Signed on 06/12/2023 09:18 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:MAPLE GUEST HOMEFACILITY NUMBER:
331881410
ADMINISTRATOR:LUNKAD, RUSHABHFACILITY TYPE:
740
ADDRESS:3485 SUGAR MAPLE COURTTELEPHONE:
(773) 672-9696
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 6CENSUS: 5DATE:
05/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Chirag Kapadia, ApplicantTIME COMPLETED:
11:00 AM
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On 5/24/2023, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an announced pre-licensing inspection at the facility. LPA Nwogene met with Applicant, Chirag Kapadia and toured the inside and out of the facility. There are currently five (5) 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.

Buildings and Grounds: The home is composed with living room, kitchen and dining room combination, five (5) clients bedrooms, 1 resident restroom, a staff room, staff bathroom, laundry room, backyard, and a garage. 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 Chirag, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished with furnitures, dressers, chairs and lighting. Privacy is available. Night lights are maintained throughout the facility. The dining and living room areas/furniture are clutter free and in good condition. Bathroom was observed to have non-slip mats and grab bar. The hot water was tested and measured at 107 degrees Fahrenheit which is within regulatory limits. Outdoor areas had sufficient room for activities. Central heating and air conditioning system installed with a central panel located in hallway to control entire house.

Storage and Supplies: Medications are stored in a locked cabinet in the kitchen, 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 are stored away in the laundry room, inaccessible to clients, washing machine and dryer are all in good repair and sufficient for the requested capacity. A Fire extinguisher was available and fully charged.

CONTINUE ON LIC809-C

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2023
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAPLE GUEST HOME
FACILITY NUMBER: 331881410
VISIT DATE: 05/24/2023
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CONTINUED FROM LIC809

Activities: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition. Facility has a big outdoor umbrella providing shade over the outside table and chairs. Activity supplies are present inside the home, including television, magazines, and games.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen cabinet, available only to authorized individuals. Trash cans has tight-fitting lids. Dishwasher will be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 37 degrees Fahrenheit and Freezer was measures at -2 degrees Fahrenheit.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Covid-19 poster, Visitors Policy, Personal Rights, rights of resident council, a Facility Sketch (LIC 999), Labor Law Information, and Complaint Information.


LPA Nwogene will inform the Centralized Applications Bureau (CAB) that the home is ready for licensure. and Applicant will be notified of the license approval.

An exit interview was conducted were this report was discussed with and provided to Chirag Kapadia.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC809 (FAS) - (06/04)
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