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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881561
Report Date: 02/14/2025
Date Signed: 02/17/2025 07:21:26 PM

Document Has Been Signed on 02/17/2025 07:21 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:TEMPLE COURTFACILITY NUMBER:
331881561
ADMINISTRATOR/
DIRECTOR:		RAHMAN, RUZEDANAFACILITY TYPE:
740
ADDRESS:40009 TEMPLE CTTELEPHONE:
(951) 249-9860
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 0DATE:
02/14/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Mohammad RahmanTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an announced pre-licensing inspection at the facility and met with Licensee Mohammad Rahman

Application: The inspection is a Change of ownership (CHOW) for a Residential Care Facility for Elderly (RCFE). The Murrieta Fire Department approved a fire clearance on 09-25-2024 for six (6) non-ambulatory clients among which bedroom one can be bedridden.

Buildings and Grounds: The facility is composed of five (5) residents bedrooms, one (1) office, three (3) bathrooms, a living room and a kitchen area. Water temperature was measured at 105.6 F. The interior and exterior walkways of the facility were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were in working order. There is a no pool and there are no weapons stored in the facility. Client bedrooms are fully furnished, and privacy is available. Outdoor areas have sufficient room for activities and leisure. A washing machine and dryer were available and in working order. The facility has a working phone witnessed by calling the phone number.

Storage and Supplies: Medications, residents and staff files will be stored in a locked cabinet in the kitchen area, inaccessible to any unauthorized individuals. A complete first aid kit was observed to be available. Cleaning supplies will be stored under the kitchen sink. Linens, and equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged with an expiration date of April 04th, 2025.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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: TEMPLE COURT
FACILITY NUMBER: 331881561
VISIT DATE: 02/14/2025
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Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and freezer are in working order. Sharps knives will be stored in a locked cabinets in the kitchen area, available only to authorized individuals.

Forms: The following signs were observed to be posted at the facility: Personal Rights, Complaint information, Emergency disaster plan, the facility sketch. LPA verified the Administrator's Certification, with an expiration date of February-11-27, and CPR certification with the expiration date of February-05-27.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. The applicant completed Comp III on February 11, 2025. LPA determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete and has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted, and this report was discussed and a copy was provided Licensee Mohammad Rahman

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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