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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881442
Report Date: 02/09/2024
Date Signed: 02/09/2024 09:55:47 AM

Document Has Been Signed on 02/09/2024 09:55 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:MURRIETA MANOR: SENIOR LIVINGFACILITY NUMBER:
331881442
ADMINISTRATOR:ARIZOBAL, IVANFACILITY TYPE:
740
ADDRESS:30903 LAELIA CIRCLETELEPHONE:
(760) 412-0321
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 0DATE:
02/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Applicant, Ivan ArizobalTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted an announced visit to the home in order to conduct an initial pre-licensing inspection. LPA met with Applicant, Ivan Arizobal.

LPA conducted a walk through and reviewed the pre-licensing documents. The facility will serve elderly ages 60 and above in a residential care facility for the elderly. The fire clearance was approved for (6) ambulatory residents.

The home is a one story home with attached garage, with (4) bedrooms, (1) staff office, and (3) bathrooms. No pools or firearms are present at the facility. LPA observed PPE equipment and hand washing stations in the facility. LPA observed the emergency supplies and emergency exits. The physical plant was observed to be in good repair and free of hazards. Provisions of safety such as grab bars were observed, The bedrooms had the required furniture along with linens. The facility kitchen can prepare food in a clean and safe environment. The facility possessed requirement amount of food supplies. The smoke and carbon monoxide alarms were tested and observed to be operational. There are designated locked areas for resident medication and sharp hazardous objects. The hot water temperature was recorded in resident restroom at 106.3F, and the land line was operational at (951) 599-4790.

There are no objections for the applicant to proceed in the pre-licensing process. An exit interview was conducted with Applicant, Ivan Arizobal, where this report ad provided to them.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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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