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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881544
Report Date: 05/09/2024
Date Signed: 05/09/2024 09:46:39 AM

Document Has Been Signed on 05/09/2024 09:46 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:MORENO BEACH HOUSE OF CAREFACILITY NUMBER:
331881544
ADMINISTRATOR/
DIRECTOR:		CHEN, JOHNFACILITY TYPE:
740
ADDRESS:27765 SOLITUDE AVENUETELEPHONE:
(949) 441-9833
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 0DATE:
05/09/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:John Chen and Angelica Ubungen, ApplicantsTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analysts (LPAs), Stephanie Martinez, Valerie Flores and Seo Jeong conducted an announced pre-licensing inspection at the home. The LPAs met with Applicants, John Chen and Angelica Ubungen. There are currently no residents in care.

Application: The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for six (6) ambulatory residents.

Buildings and Grounds: The home is composed of four (4) resident bedrooms, three (3) bathrooms, one office, a garage, laundry room, living room, an open kitchen and dining area, and front and back yard areas. The interior and exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Chen, there are no weapons stored in the home. Rooms, furniture, beds, mattresses were all in good repair. The bedrooms are furnished, and privacy is available. The dining and living room areas are clutter free and furniture is in good condition. The resident bathrooms were observed to have non-slip mats available. The hot water was tested and measured at 110.4 degrees Fahrenheit, which is within regulatory requirements. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order.

Storage and Supplies: Activities were observed to be available. Medications will be stored inaccessible to any unauthorized individuals. Designated areas are available for facility files, staff files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in a locked area. Linens, and equipment are all in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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: MORENO BEACH HOUSE OF CARE
FACILITY NUMBER: 331881544
VISIT DATE: 05/09/2024
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Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked cabinet, available only to authorized individuals.

Forms: The following signs were observed to be posted at the home: Theft and Loss Policies, Personal Rights, Resident/Family Councils, and Complaint Information.

The following was observed to require follow up: A gate is needed to secure the backyard area, a hole on the side of the outside of the home, which has exposed pipes, needs to be filled in, and extra seating at the dining table needs to be obtained.

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensing once proof of corrections are received from the applicants. This report was discussed, and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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