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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881410
Report Date: 08/01/2024
Date Signed: 08/01/2024 12:41:04 PM

Document Has Been Signed on 08/01/2024 12:41 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:MAPLE GUEST HOMEFACILITY NUMBER:
331881410
ADMINISTRATOR/
DIRECTOR:		LUNKAD, RUSHABHFACILITY TYPE:
740
ADDRESS:3485 SUGAR MAPLE COURTTELEPHONE:
(773) 672-9696
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 6CENSUS: 3DATE:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:HOUSE MANAGER, CHARMAINE WILLIAMSTIME VISIT/
INSPECTION COMPLETED:
12:48 PM
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On August 01, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the House Manager, Charmaine Williams. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for six Elderly Adults (740) and is currently operating at a capacity of three Adults.

The facility is a single story home with five bedrooms and two bathrooms and an attached garage. LPA Mixson conducted a tour of the facility, along with the House Manger, inside and out, reviewed facility documents and conducted interviews following is a summary of visit.

Infection Control: LPA Mixson observed hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs, along with personal hygiene items and equipment used for cleaning.

Physical Plant: LPA Mixson observed resident bedrooms. Physical plant, floors, windows, and doors were clean and fixtures and furniture were in good repair. The facility's outdoor area was free of hazards and contained outdoor furniture and shaded area for outdoor activities and family visits. Laundry equipment was in good working condition currently at the time of this visit. The sharp items and cleaning solutions were locked and inaccessible to residents in care. The smoke detectors and carbon monoxide detectors were observed and operational. Hot water temperature tested within regulations and there is a first aid kit locked and inaccessible to the residents in care.

Food Service: LPA Mixson observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required two day supply of perishable and seven day supply of non-perishable foods, and had a variety of food types.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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: MAPLE GUEST HOME
FACILITY NUMBER: 331881410
VISIT DATE: 08/01/2024
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Care & Supervision/Administration: Adequate staff are present for the care and supervision at the time of this visit. LPA Mixson reviewed Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were observed posted throughout the facility. The Administrator's certification is Posted and current at the time of this visit.

Records Reviewed: Resident/Staff Files: LPA Mixson reviewed staff files, training, and files were seen to contained staff criminal clearance and updated training. Resident files were reviewed and possessed required paperwork currently at the time of this visit.



Health Related Services/ Incidental Medical Services: Medications were locked and inaccessible to the residents in care in the kitchen area. LPA Mixson reviewed client medications and reviewed medications listed on medication administration report (MARS), and required labeling was observed with no concerns.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan and reviewed documentation showing the facility holds monthly fire and earthquake drills, which was last conducted in February of 2024 and meets the department requirements. LPA observed facility exits were clear from obstructions and/or debris. LPA Mixson reviewed emergency supplies in the garage, along with water and food.

There were no Title 22 Division 6 Regulations cited or observed at the time of the visit.

An exit interview was conducted and a copy of this report was discussed and provided to House Manager.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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