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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881585
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:23:40 PM

Document Has Been Signed on 09/27/2024 12:23 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A PETERSON RCFEFACILITY NUMBER:
331881585
ADMINISTRATOR/
DIRECTOR:		PETERSON, GARRETTFACILITY TYPE:
740
ADDRESS:5 SHASTA LAKE DRIVETELEPHONE:
(760) 464-0882
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY: 6CENSUS: 3DATE:
09/27/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Garrett Peterson & Terrye Peterson, LicenseesTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:30 AM, LPA met with Licensee/Administrator Garrett Peterson & Terrye Peterson . An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 08/01/2022 for a total capacity of six (6), five (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 07/01/2024. LPA Delgado observed the following:
Structure:
Facility was a one-story house with five (5) resident bedrooms, three (3) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house.
Heating/Cooling System:
There are two (2) Central heating and air conditioning system installed with a panel located inside bedroom #1 and in the hallway to control each section of the house.
Bedrooms:
Each resident bedroom #2, #3, #4 and #5 will accommodate any non-ambulatory resident, shared bedroom #1 will accommodate one (1) bedridden residents and one (1) non-ambulatory resident. 5 resident bedrooms were adequately furnished with bed-bedroom #4 had no bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
Three (3) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of toilet paper, and soap. At 11:00 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.3 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked closet next to the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.
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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A PETERSON RCFE
FACILITY NUMBER: 331881585
VISIT DATE: 09/27/2024
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(CONTINUED FROM PAGE 1)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the garage. Laundry detergents were observed in garage away from residents and cleaning supplies stored inside the cleaning closet next to the garage.
Living/Family room:
There was a living room with seating for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence and hygiene supplies stored in a closet in the hallway .
Yards/Outside:
Patio table and chairs were observed in the backyard. There was a gate on the South side and North side of the property with a self-latching. All outdoor pathways were free of obstructions. Pool was observed with a 5 foot perimeter mesh/metal gate surrounding the pool and no fire arms will be stored on the premises.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway. Ombudsman poster and Let-Us-No poster observed.
General items:
Three (3) fire extinguishers were charged and located in the kitchen, outdoor and garage. Seven (7) dual smoke alarms/carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the Family room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and food suppy was observed. Cameras located in the common areas: living room, kitchen, hallway, medication cabinet, front door and garage that record with no audio for 5 days at time. Component III is scheduled for October 16, 2024.

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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A PETERSON RCFE
FACILITY NUMBER: 331881585
VISIT DATE: 09/27/2024
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Pre-Licensing is incomplete and the following corrections to be resolved by 10/14/2024:

Update Plan of Operation to include the cameras in the common areas
Update Admission agreement to include the notification of the cameras in the common areas
Request Hospice Waiver for a total of six (6)
Setup bed in room #4
obtain two (2) exterior window screens
obtain trash cans with lid for resident bathrooms
obtain paper towel stands
obtain lamp for bedroom #5

An exit interview was conducted, and a copy of this report was given.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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