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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881577
Report Date: 10/29/2024
Date Signed: 10/29/2024 10:46:20 AM

Document Has Been Signed on 10/29/2024 10:46 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:MOUNT VERNON RCFE LLCFACILITY NUMBER:
331881577
ADMINISTRATOR/
DIRECTOR:		SOTTO MONICA ROSEFACILITY TYPE:
740
ADDRESS:2225 MT VERNON AVETELEPHONE:
(951) 232-5422
CITY:RIVERSIDESTATE: CAZIP CODE:
92507
CAPACITY: 6CENSUS: 0DATE:
10/29/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Monica Rose SotoTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst, (LPAs) Armando Perez and Abdoulaye Zerbo made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA met with Applicant, Monica Rose Soto and Alex Soto, who accompanied LPAs for the inspection. Applicant has submitted an application for five (5) ambulatory residents and one (1) non ambulatory. On September 5, 2024, Riverside City Fire Department approved a fire clearance for the facility.

The facility is a one story home with 5 client bedrooms, 3 bathrooms, laundry room, living room, dining area, kitchen, and attached garage. LPAs observed clients’ bedrooms with the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, chairs, lighting, and emergency lighting. Client bathrooms had the required hand bars near toilet and in shower and non slip mats present inside showers. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Sharps, such as knives and scissors, will be stored in a locked kitchen cabinet.

Client files, staff files, first aid kit and emergency food and water will be stored in a locked storage room accessible through the living room. Client medication will be centrally stored and locked in the same storage room accessible through the living room. The facility has no pool or any bodies of water. There is a covered patio area with sufficient seating for all the clients. All passageways were free from obstruction. LPAs observed 1 charged fire extinguisher in the facility with the expiration date of December 2025. Applicant is aware the fire extinguisher must be renewed yearly and has until the end of 2025. The smoke detectors and carbon monoxide alarms were operational. LPAs observed a covered fireplace in the dining area that appears to be inoperable. The facility does not have any known firearms and ammunition on the property. LPAs observed the required postings of the emergency disaster plan, resident personal rights, complaint procedures, employee rights, visitation rights, facility sketch, and the Long-Term Care Ombudsman poster.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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: MOUNT VERNON RCFE LLC
FACILITY NUMBER: 331881577
VISIT DATE: 10/29/2024
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. Facility contains emergency supplies and first aid kits with the required items. The facility has working telephone for client use. LPAs observed Applicant's Administrator Certification with expiration date of 7/29/26 and a valid CPR certification on file with expiration date of 09/04/2026.

LPA’s observed a 20x10 structure in the backyard located about 120 feet from the main house. Applicant states that it will be used for storage only. Applicant will need to email LPA with the updated floor plan to document the storage structure in the backyard by the property line.

LPAs observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPAs determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete and this facility has no issues or concerns. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Applicant, Monica Rose Soto.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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