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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881569
Report Date: 05/08/2024
Date Signed: 05/08/2024 03:13:25 PM

Document Has Been Signed on 05/08/2024 03:13 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:GENTLE CARE ESTATES LLCFACILITY NUMBER:
331881569
ADMINISTRATOR/
DIRECTOR:		HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:18183 HAINES STTELEPHONE:
(786) 564-3771
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 6CENSUS: 2DATE:
05/08/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Licensee, Ebraheem HamedTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Janette Romero made an announced visit to the facility to conduct a pre-licensing evaluation. The facility submitted a change of ownership application to the Centralized Applications Bureau (CAB). LPA met with Licensee, Ebraheem Hamed. On 4/22/2024, the facility was granted a fire clearance for a total capacity of six (6) non-ambulatory elderly residents.

LPA toured the facility's interior and exterior with Licensee Hamed. The facility is made up on a one-story home with six resident (6) bedrooms, five (5) bathrooms, two (2) living rooms, a kitchen, dining room, activity room, and detached car garage. Indoor and outdoor passageways are free of obstruction. There are no bodies of water on the premises. Licensee Hamed tested one of the smoke alarm/carbon monoxide detectors and LPA found it to be operational. The facility has a central heating and air conditioning system installed with a central panel located in the living room to control entire house. All resident bedrooms are adequately furnished with a bed, chair, closet, appropriate sized linens, adequate lighting, and a smoke alarm/carbon monoxide detector. All bathrooms have a working toilet, wash basin, and have toilet paper, paper towels, and soap readily available. Three of the facility's bathrooms have showers. Bathrooms with showers have grab bars near the toilet and in the showers. LPA tested three (3) of five (5) bathroom's water temperatures, which measured at 104.9, 106.1 and 108.3 degrees Fahrenheit. LPA toured the kitchen and observed the facility has a sufficient supply of dishes, glasses, utensils, pots and pans for the approved capacity. Knives/sharp instruments are secured in a kitchen drawer. Medications are centrally stored in the administrator's office. Cleaning solutions and disinfectants are secured in a locked kitchen cabinet. The facility has a confidential storage area designated for staff and resident records. Emergency phone numbers, personal rights and Long Term Care Ombudsman information are posted near the living rooms.

During today's visit, LPA did not observe any issues or concerns, and there are no corrections required. Final approval of licensure will be granted by the CAB analyst. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee Hamed.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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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