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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881643
Report Date: 10/21/2024
Date Signed: 10/21/2024 02:14:00 PM

Document Has Been Signed on 10/21/2024 02:14 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:NANA NIDA'S HAVENFACILITY NUMBER:
331881643
ADMINISTRATOR/
DIRECTOR:		GERADA, J NIDAFACILITY TYPE:
740
ADDRESS:31-760 AVENIDA DEL PADRETELEPHONE:
(760) 219-7868
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 0DATE:
10/21/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:GERADA, J NIDATIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analysts (LPAs),Abdoulaye Zerbo, Debbie Pelacio and Licensing Program manager (LPM) Tricia Danielson conducted an announced pre-licensing inspection at the facility and met with Applicant, Gerada Nida

Application: The inspection is for an initial Residential Care Facility for Elderly (RCFE) application. The Riverside County Fire Department approved a fire clearance for six (6) non-ambulatory clients on 08-29-2024.

Buildings and Grounds: The home is composed of six (6) client bedrooms,a living room area, six (6) bathrooms, a laundry room, kitchen and dining area, a garage, and front and back yard. The interior and exterior walkways of the home were observed to be clutter free with no obstructions. Smoke and Carbon Monoxide detectors are hard wired in working order. There is no gated pool and no weapons stored in the home. Client bedrooms are fully furnished, and privacy is available. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer were available and in working order.

Storage and Supplies: Medications will be stored in a locked pantry next to the kitchen, inaccessible to any unauthorized individuals. Secured locked cabinets next to bedroom 1 are available for facility files, staff files and client files. A complete first aid kit was observed to be available. Cleaning supplies will be stored away in a secured location in the garage. Linens, and equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged with an expiration date of 04-12-2025.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and freezer are in working order. Sharps knives will be stored in a locked pantry, available only to authorized individuals.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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: NANA NIDA'S HAVEN
FACILITY NUMBER: 331881643
VISIT DATE: 10/21/2024
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Forms: The following signs were observed to be posted at the home: Personal Rights, Complaint information, Emergency disaster plan, the facility sketch, ombudsmands poster. LPAs verified the Administrator's Certification, with an expiration date of July 10 , 2025 and CPR certification with the expiration date of January 16, 2025

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 10-16-2024. 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 Gerada Nida.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC809 (FAS) - (06/04)
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