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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881599
Report Date: 07/30/2024
Date Signed: 07/30/2024 11:03:32 AM

Document Has Been Signed on 07/30/2024 11:03 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:EMERALD ROSE GARDEN 3FACILITY NUMBER:
331881599
ADMINISTRATOR/
DIRECTOR:		NAVAREZ, JULIEFACILITY TYPE:
740
ADDRESS:78484 EWARTON RDTELEPHONE:
(909) 533-0642
CITY:BERMUDA DUNESSTATE: CAZIP CODE:
92203
CAPACITY: 6CENSUS: 0DATE:
07/30/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Applicant Julie NavarazTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 7/30/24 Licensing Program Analyst (LPA) Valerie Flores made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA Flores met with Applicant Julie Navarez, who accompanied LPA Flores for the tour of the facility. The Applicant has submitted an application for 6 residents to which she was approved for six (6) non-ambulatory residents, of which one (1) may be bedridden in the master bedroom. Applicant is also approved for six (6) hospice care waivers. On 7/5/24 the Riverside County Fire Department approved a fire clearance for Master bedroom (room 1) to which may accept any bedridden or non-ambulatory residents, bedrooms two (2), three (3), and four (4) may accept any ambulatory/non-ambulatory residents. There is a casita located in the front west wing of the home that is dedicated for staff use only. Per applicant, they do not have any live-in staff at this moment but may apply for it at a later date.

The home is a single-story structure consisting of five (5) bedrooms, five (5) bathrooms, kitchen, formal dining room, family room, garage, and a backyard. The bedrooms were observed to have met the required bedding and furniture (i.e., bed, lighting, night stand, dresser, and area for sitting). The bathrooms had non-skid mats, and grab bars. There are plenty of extra linen (sheets, blankets, towels) that were observed to be in good repair stored in the laundry room .One (1) fully charged fire extinguisher was located in the kitchen. A locked cabinet was observed by the master bedroom that stored staff and resident files. A locked cabinet was observed in the kitchen for centrally stored medication.

The hot water temperature was measured at 109.7 degrees Fahrenheit meeting within the required limits. The facility has an emergency disaster plan and approved infection control training plan on file. The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair. The facility maintained the required two (2) day supply of perishable and a seven (7) day supply of nonperishable food items. The facility has an emergency food and water supply. There is a fully stocked first aid kit. Indoor and outdoor passageways were free of obstruction.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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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: EMERALD ROSE GARDEN 3
FACILITY NUMBER: 331881599
VISIT DATE: 07/30/2024
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Outdoor patio with a shaded seating area was available for residents. The backyard is gated and there are no bodies of water observed on the premises. Per Applicant Navarez, there are no firearms or ammunition on the premises.

The hallway leading to resident room three (3) and (4), LPA Flores observed the required postings of the facility sketch, personal rights, employee rights, PUB475 CCLD Complaint poster and the Long term Care Ombudsman poster.



During today's visit, LPA Flores did not observe any issues or concerns. Applicant is scheduled to attend COMP III at the Riverside Regional Office on 8/20/24. Final approval of licensure will be determined by CAB.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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