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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881479
Report Date: 01/16/2025
Date Signed: 01/16/2025 05:10:53 PM

Document Has Been Signed on 01/16/2025 05:10 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:A & S SENIOR QUALITY CAREFACILITY NUMBER:
331881479
ADMINISTRATOR/
DIRECTOR:		FUENTES, TERESAFACILITY TYPE:
740
ADDRESS:17764 ROBUSTA DRIVETELEPHONE:
(909) 548-1769
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 6DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:House Manager Cheryl GrantTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with house manager, Cheryl Grant. The LPA informed the manager of the purpose for the visit. The inspection included the following:

The facility consists of four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. There are no firearms at this home and no bodies of water observed.

LPA began review of client records. six (6) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available.

LPA began review of employee records- four (4) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 09/19/2025. LPA observed personnel records to be available and complete. LPA observed facility dues to be outstanding. Administrator was informed and provided the PIN number to complete payment.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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: A & S SENIOR QUALITY CARE
FACILITY NUMBER: 331881479
VISIT DATE: 01/16/2025
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Medications are centrally stored. There is a locked cabinet in the kitchen allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Administrator stated smoke detectors and carbon monoxide detectors are a combined unit and were tested and found to be operational. Fire extinguishers meets requirements and are valid until, 12/31/2025. The facility is conducting emergency disaster/fire drills quarterly; last done on 01/14/2025.

Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809 report was reviewed with the facility representative and a copy was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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