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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881526
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:08:31 PM

Document Has Been Signed on 01/16/2025 02:08 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:IRIS FAMILY HOME CAREFACILITY NUMBER:
331881526
ADMINISTRATOR/
DIRECTOR:
KINCHERLOW, JACQUELINE IFACILITY TYPE:
740
ADDRESS:1712 BRIDLE TRAILTELEPHONE:
(951) 665-6092
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 6CENSUS: 2DATE:
01/16/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:58 PM
MET WITH:ADMINISTRATOR, JACQUELINE KINCHERLOWTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On January 16, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility to conduct a case management visit in order to make observations pertaining to the changes from ambulatory to non ambulatory and bedridden.

Physical Plant: The location is a single-story home located at 1712 Bridle Trail San Jacinto, CA. 92582, and has four bedrooms, three full bathrooms, a living room, dining room, and a kitchen, with a two-car garage. A backyard and front yard. The Riverside Fire Department approved this facility for zero (0) Ambulatory, five (5) Non-Ambulatory, and one (1) bedridden residents, on December 20, 2024. The home has a first aid kit and manual, the Administrator has received First Aid and CPR training.

Medications: Were stored, locked, and inaccessible to the residents. The home is equipped with lights in the passages and stocked with emergency night lights. The smoke and carbon monoxide detectors were observed and are operable. The fire extinguisher is charged and in the green. Cleaning supplies were locked and inaccessible, along with the sharp objects.

Bedrooms: Were large enough to allow for easy passage between the beds, and other required items of furniture were present. There was sufficient lighting for residents. Rooms were large enough to support the increase to five non ambulatory.

Kitchen/Food: The knives were locked in a kitchen drawer, plenty of pots, pans, and other kitchen accessories. The facility has the required seven-day supply of non-perishable food items and the two-day supply of perishable food items. LPA Mixson observed hygiene supplies for residents. There were no pesticides, poisons, or other toxic substances stored near any food storage or preparation area.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: IRIS FAMILY HOME CARE
FACILITY NUMBER: 331881526
VISIT DATE: 01/16/2025
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Records: There is confidential storage space for personnel records.

Bathrooms: The bathrooms floors were clean and sanitary and free of odors, water and other appliances were operable, water temperature tested within regulations. There was at least one toilet and sink for each six persons to include residents and at least one bathtub/shower for each ten persons which includes residents, family and/or live-in personnel.

Administration: Emergency exiting plans and telephone numbers posted, Personal Rights, Complaint Poster, and other required documents were posted. The current Administrators certification is posted with an expiration date of 04/19/2025. The facility theft and loss program policy are posted.

Activities: There are activity supplies and equipment available for residents. Including access to daily newspapers, current magazines, and a variety of reading materials in the language of choice.

Miscellaneous: There is a first aid kit, including sterile dressings, bandages, thermometer, and other items as required by regulations. There are laundry supplies and equipment, including machine in good repair, and there is space for clean linen storage and a separate space for soiled linen. LPA Mixson observed emergency lighting supplies to include flashlights, and extra batteries, along with vehicles used to transport residents.

There were no observable regulation violations. An exit interview was conducted and a copy of this report was provided to the Administrator, Jacqueline Kincherlow.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
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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