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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881600
Report Date: 11/21/2024
Date Signed: 11/21/2024 10:25:57 AM

Document Has Been Signed on 11/21/2024 10:25 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:GAVILAN MANORFACILITY NUMBER:
331881600
ADMINISTRATOR/
DIRECTOR:		RILLO, EFRENFACILITY TYPE:
740
ADDRESS:24195 SPENCER BUTTE DR.TELEPHONE:
9513472809
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 6CENSUS: 0DATE:
11/21/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:18 AM
MET WITH:Efren Rillo AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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Licensing Program Analysts (LPAs) Ferrer Sabarias and Abdoulaye Zerbo made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPAs met with applicant, Efren Rillo, who accompanied LPAs for the inspection. The Applicant has submitted an application for six (6) residents. On 6/26/2024 the Riverside County Fire Department approved a fire clearance for six (6) non ambulatory residents.

Facility is a one story building with 3 residents bedrooms, 2 staff bedrooms and 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 clean appliances that were operating in safe and sanitary condition and the showers contained non-slip surface. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Facility met the required 2-day supply of perishable food and 7-day supply of non-perishable foods. Water temperature in the kitchen and bathrooms measured within regulation at 106.3 degrees F.

Client and staff files will be locked in the hallway cabinet. Client medication will be centrally stored and locked in the hallway cabinet. The facility has a pool with the locked fencing requirements. There is a covered patio area with seating for all the clients. All passageways were free from obstruction. LPAs observed two fire extinguishers in the facility with the last service date of 05/24/24. The smoke detectors and carbon monoxide alarms were operational. Applicant stated that there are no known firearms and ammunition on the facility.

Continue to LIC809C

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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: GAVILAN MANOR
FACILITY NUMBER: 331881600
VISIT DATE: 11/21/2024
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Continued from LIC809

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. Facility contains emergency supplies and first aid kits with the required items. The facility has working telephone in the facility.

LPAs observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. The applicant has completed COMP III orientation on 11/19/2024 and the Administrator has an active administration certificate valid until 12/16/2024 and CPR/AED/First Aid until 6/24/2026 LPAs 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 provided to applicant Efren Rillo.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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