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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881433
Report Date: 06/20/2023
Date Signed: 06/20/2023 01:39:21 PM

Document Has Been Signed on 06/20/2023 01:39 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CASA HERMOSILLAFACILITY NUMBER:
331881433
ADMINISTRATOR:HERMOSILLA, MARLON MFACILITY TYPE:
740
ADDRESS:79870 BARCELONA DRIVETELEPHONE:
(760) 409-6181
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 6CENSUS: 6DATE:
06/20/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Marlon HermosillaTIME COMPLETED:
01:36 PM
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Licensing Program Analyst (LPA), Jacqueline Shaw Ross conducted an announced pre-licensing inspection at the facility and met with applicant, Marlon Hermosilla. Also present at the facility was Licensee's wife. Licensee stated his wife is a full time Registered Nurse and does not work at the facility as a employee. Licensee states she just showed up today to help with paperwork only. LPA advised Licensee to obtain background clearance for his wife if visits become frequent.

Application: The application is for a Residential Care for the Elderly facility (RCFE) change of ownership. The fire clearance has been granted for six (6) clients total. Bedroom one (1) is approved for Non-ambulatory with a maximum of two (2) clients. Bedrooms two (2) through five (5) are approved for ambulatory clients. Fire clearance was granted on 05/4/2023.

Buildings and Grounds: The home is a one-story facility composed of five (5) client bedrooms, one (1) staff guestroom, three (3) bathrooms, a living room area, kitchen and dining areas, garage, a laundry area in the garage, and front/back yard areas. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors are in working order. There are no pools or other bodies of water located at the home. No firearms. Bedrooms were in good condition and are appropriately furnished. All bathrooms have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and hand soap dispensers. Hot water was tested in the resident bathrooms. LPA verified water temperature was measured at 108 degrees Fahrenheit. The dining and living room areas are clutter free and in good condition. Outdoor areas had sufficient room for activities and leisure. A washing machine and a dryer were observed to be fully functioning in the garage area.

Storage and Supplies: Medications, facility files and client files are stored in a locked hallway closet, inaccessible to any unauthorized individuals.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CASA HERMOSILLA
FACILITY NUMBER: 331881433
VISIT DATE: 06/20/2023
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(CONTINUED FROM LIC 809)

The first aid kit was observed to be available and complete. Cleaning supplies are stored away in the garage. Linens and equipment appeared to be in good repair. Fire extinguishers were available and fully charged.

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 drawer, available only to authorized individuals.

Forms: Appropriate signage is posted throughout the facility.

No needed corrections were observed to be needed at time of visit. The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure. This report was discussed with and a copy provided to the applicant.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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