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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881485
Report Date: 03/05/2024
Date Signed: 03/05/2024 11:26:43 AM

Document Has Been Signed on 03/05/2024 11:26 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:RAINBOW RIDGE MANORFACILITY NUMBER:
331881485
ADMINISTRATOR:CASTELLANOS, JENNYFACILITY TYPE:
740
ADDRESS:45410 BAYBERRY PLTELEPHONE:
(951) 216-8130
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 8CENSUS: 6DATE:
03/05/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jenny Castellanos, Licensee/AdministratorTIME COMPLETED:
11:40 AM
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Licensing Program Analyst( LPA) Javina George made an announced visit to the facility to conduct a pre-licensing inspection due to a Change of Ownership (CHOW), with six (6) residents in care. LPA met with the Licensee/Administrator Jenny Castellanos whom accompanied LPA for the duration of the inspection. The home is licensed to have six (6) non- ambulatory residents, with 1 of which may be bedridden, and reside in bedroom #5 only. At this time the facility does not have a bedridden resident, therefore the room is vacant.

The facility is a single story home with six (6) bedrooms, 1 of which is a designated staff bedroom, and two and a half (2.5) bathrooms, attached garage, kitchen, backyard, formal living room and family room. LPA conducted a tour of the interior and exterior of the facility. The following was observed during today's inspection:

LPA observed for the kitchen ceiling to have four (4) separate water stains. Per the Licensee Jenny, the roof was repaired and just needs to have the ceiling painted, she will follow up with the home owner. The facility has a sufficient supply of dishes, cooking and eating utensils, and linens that were observed to be in good repair.

The passageways, and ramps/inclines were clear and free from obstruction. The home has a fully charged fire extinguisher. There are three (3) carbon monoxide and multiple smoke detectors strategically placed throughout the facility that were tested and observed to be operable. The facility does not have any known guns or ammunition stored on grounds. The sharps/knives and medication are stored inside the kitchen in a locked drawer and cabinet. The chemicals are stored inside a locked cabinet inside the laundry room. The hot water was tested in both bathrooms and measured to be between 116.9-120 degrees Fahrenheit.

LPA observed for the rooms to be fully furnished with a bed, lamp, night stand, and adequate lighting. The hallways are well lit. The facility has working flashlights as well as a lantern to use in the event of a power outage. The facility was observed to have the required postings (license, administrator certificate, personal rights, theft and loss, PUB475 complaint poster) on a wall located inside the kitchen. The Long term Care
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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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: RAINBOW RIDGE MANOR
FACILITY NUMBER: 331881485
VISIT DATE: 03/05/2024
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Ombudsman poster is posted on the wall in the hallway outside of the master bedroom.

The facility has several activities to encourage socialization such as karaoke, puzzles, bingo, arts and crafts as well as a covered patio with plenty of outdoor space to garden or walk. The facility food supply was observed to be sufficient as there was 2 day supply of perishable and a 7 day supply of nonperishable food items.

Three residents were observed to be sitting in the family room, groomed, and greeted LPA with a smile, the residents were observed watching a game show on the television, debating if they wanted to go outside. The facility was observed to have cameras in the common areas (living room, family room). However per the Licensee the facility staff do not have access to the codes and the cameras are not functional at this time. Therefore video surveillance was not included in the facility's plan of operation.

It is the recommendation that the home to be licensed upon successful completion of COMP III orientation.

An exit interview was conducted and a copy of this report was provided to Jenny Castellanos, Licensee/Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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