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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881530
Report Date: 12/02/2024
Date Signed: 12/02/2024 12:53:41 PM

Document Has Been Signed on 12/02/2024 12:53 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:LOVING CARE #2FACILITY NUMBER:
331881530
ADMINISTRATOR/
DIRECTOR:
BUSBY, SYLVIAFACILITY TYPE:
740
ADDRESS:43707 ALCOBA DRIVETELEPHONE:
(951) 694-6779
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 6CENSUS: 3DATE:
12/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Applicant, Sylvia BusbyTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Janira Arreola, made an announced visit to the facility in order to conduct a pre licensing inspection. LPA met with Applicant, Sylvia Busby who was informed of the purpose of the visit.

The facility is seeking a change in ownership with residents in care. The facility will be licensed as a residential care facility for the elderly, with capacity of (6) residents. Hospice waiver is granted for (6) residents. The facility is approved by the local fire jurisdiction for (6) non-ambulatory residents, (1) of which may be bedridden in Room (1), and approved for ambulatory residents only in Room (4). The facility does not have a pool or firearms.

Physical Plant: LPA conducted a walk through of the interior and exterior of the facility. There were (2) staff and (3) residents during the time of the visit. Adequate staff are present during the time of the visit. There are (5) bedrooms and (2) bathrooms. The bedrooms have all the required furniture, required hygiene supplies, PPE, and linens. LPA observed the hallway lights, smoke and carbon monoxide detectors in good working condition. The outdoor area was free of any hazards and had a shaded area for residents and an emergency exit. The kitchen had the ability to prepared food is a clean and safe environment. The facility had the required 2-day supply of perishable food and 7-day supply of non-perishable foods. The hot water temp was measures at 109F. The facility has a land line at (951) 303-1697. The required postings are found in the facility.

Facility Files: LPA observed areas were the staff and resident files would be kept as well as locked areas designated for medication, sharp objects, and cleaning supplies. All residents have a MARS log for medications. The current administrator has a current certificate. All staff have criminal record clearance and required training documented in their file. Residents had all required documents in their file.

There are no objections for the applicant to proceed in the pre licensing process. An exit interview was conducted with the applicant, and copy of this report was reviewed and provided to them.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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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