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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881429
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:57:02 PM

Document Has Been Signed on 11/14/2024 03:57 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PARTNERS IN CARE OF ADDISON WAYFACILITY NUMBER:
331881429
ADMINISTRATOR/
DIRECTOR:		HECHANOVA, MARJORIEFACILITY TYPE:
740
ADDRESS:4659 STRATFORD PLACETELEPHONE:
(818) 400-4667
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 5DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:09 PM
MET WITH:Staff, Archie DinjotianTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analysts (LPAs) Janira Arreola and Debbie Palacios conducted an unannounced annual required visit. LPA was granted entry by Staff, Archie Dinjotian. The Administrator and Licensee, Marjorie Hechanova was available over the phone during the visit. The staff was informed of the purpose of the visit. At the time of the visit there were (2) staff and (5) residents present.

The facility is a one story home with (4) bedrooms and (3) bathrooms for clients. No pools or firearms are being kept at the facility. The residents served are elderly ages 60 and above. LPAs conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPAs observed the following:

Infection Control: The LPAs observed the hand washing stations and hygiene supplies. LPAs observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPAs reviewed the facility's infection control plan which met department requirements.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature 112F.

Food Service: LPA 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 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 2
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: PARTNERS IN CARE OF ADDISON WAY
FACILITY NUMBER: 331881429
VISIT DATE: 11/14/2024
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPAs also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator had proof of submitting their renewal for administrator's certificate. Licensee, Gerry Hechanova had a current administrator's certificate.

Record Review and Resident/Staff Files: LPAs reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in file cabinets. LPAs reviewed medications for (2) resident and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill was conducted on 10/5/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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