<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881430
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:01:41 PM

Document Has Been Signed on 10/25/2023 12:01 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:CASA DEL SOL RESIDENTIALFACILITY NUMBER:
331881430
ADMINISTRATOR:KHAN, MUSARRATFACILITY TYPE:
740
ADDRESS:27830 BRODIAEA AVENUETELEPHONE:
(909) 282-2316
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 0DATE:
10/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:ADMINISTRATOR, MUSARRAT KHANTIME COMPLETED:
12:12 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 25, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived for a scheduled visit for the purpose of conducting a pre-licensing inspection and met with Administrator, Musarrat Khan, introduced herself, and stated the purpose of the visit.

LPA Mixson toured the home inside and outside, along with the Administrator. The location is a single-story home with four bedrooms, three full bathrooms, a living room, dining room, activity room, kitchen, and two car garage with backyard and front yard. On 09/19/2023, The Moreno Valley Fire Department approved this location for four non-ambulatory, and two bedridden residents, for a total of six residents. LPA Mixson observed where the medications will be stored, locked, and inaccessible to residents. The home is equipped with lights in the passages and stocked with emergency night lights throughout the home. The smoke and carbon monoxide detectors were observed, tested by the fire department, and are operable. The LPA observed one fire extinguisher it was charged and in the green. The LPA observed cleaning supplies locked and inaccessible to future residents. The sharp objects are locked in a kitchen drawer, plenty of pots, pans, and other kitchen accessories. All facility doors, and passageways are clear from obstruction. There were no bodies of water, and/or fireplaces observed at the location. The LPA observed beds have the required linen and supplies. There was enough extra clean linen and hygiene items. There was appropriate lighting in each room with nightstand, dresser, and chair. The facility has central heating and air conditioning systems, Internet and WFI for residents in place and are operable. The Administrator dialed the facility land line phone number (951)208-1886, and it was operable.
Outside/Yards: No obstructions observed. Component III completed at the Riverside RO on 10/12/2023, at 9:00am. An exit interview was conducted, a copy of this report was provided to Administrator, Musarrat Khan.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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 1