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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530219
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:08:47 PM

Document Has Been Signed on 10/03/2024 12:08 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SOUTHERN COMFORT CARE HOME 2FACILITY NUMBER:
335530219
ADMINISTRATOR/
DIRECTOR:		RIMORIN, MAE SHANDAFACILITY TYPE:
740
ADDRESS:32826 BIRCHALL COURTTELEPHONE:
(310) 975-5634
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 0DATE:
10/03/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Applicant, Joanne Casten and Administrator Shanda Mae RimorinTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 10/03/24 at 9:10AM, Licensing Program Analysts (LPA's) Renese Howell-Small and Melody Brown conducted an announced visit to the facility for the purpose of a Prelicensing Visit. LPA's met with Applicant Joanne Casten and Administrator Shanda Mae Rimorin. An initial application for license to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 06/15/24 for a total capacity of six (6). Fire clearance was granted on 06/05/24 for five (5) non-ambulatory residents and one (1) bedridden. LPA's Howell-Small and Brown observed the following:
Structure:
Facility was a single story house with six (6) bedrooms; six (6) bedrooms for residents and no staff bedrooms, three (3) resident/staff bathrooms, living room, dining area and kitchen. There is an attached two (2) car garage.

Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control the entire house. LPA's Howell-Small and Brown observed the temperature to be 72 degrees Fahrenheit.

Bedrooms:
Each resident bedroom accommodates any non-ambulatory resident. Room "F" is the only approved room for bedridden. All resident bedrooms were adequately furnished with bed, closet, appropriate linen and an operable combined carbon monoxide/smoke alarm. Technical Assistance given for mattress pads, lamps, dressers and chairs for the bedrooms.
Bathrooms:
The three (3) staff/resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPA's tested the water temperature in the resident bathrooms. LPA's verified water temperature was measured at 110 degrees Fahrenheit.
Continued on LIC809C
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219
VISIT DATE: 10/03/2024
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 ***CONTINUED FROM LIC809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked cabinet located in the hallway. There was adequate room for food storage. LPAs observed the stove to be operational. Refrigerator/freezer were in working condition. There is more than seven (7) days’ supply of non-perishable foods and more than two (2) days’ supply of non-perishable foods. There’s an adequate seating for meals for all residents. Laundry room with washer and dryer. Laundry detergents and cleaning supplies are stored in the chemical storage room. Technical Assistance given to provide trash bins with tight fitting lids.
Living/Family room:
There’s a living/family room with adequate seating for all residents and a working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
Patio furniture for outdoor seating observed. Gates on the right side of the facility. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted in the hallway. Ombudsman poster, Let-Us-No poster, Personal Rights, Emergency Disaster Plan were observed.
Dementia Care Plan:
LPAs Renese Howell-Small and Melody Brown observed and reviewed the Dementia Care Plan during the visit.
General items:
two (2) fire extinguisher(s) were charged and located throughout the facility. Dual smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Resident records will be stored in a locked cabinet in the office room. First Aid kit with required components, First Aid book and locked area for medication storage was observed. LPA's observed a facility phone and was operational as evidenced of LPA dialing the number.

***CONTINUED ON LIC 809C***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219
VISIT DATE: 10/03/2024
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 ***CONTINUED FROM LIC 809C**

The phone number designated for the facility is (951) 599-0172. The required 72-hour emergency food supply was observed. Technical Assistance given to obtain additional water and emergency supplies.

Component III was completed on this day as well. LPAs observed activities for the residents such as books, games and magazines. Additionally, upon entry, LPAs observed the facility having Visitor Sign In/Sign Out Sheet and Resident Sign In/Sign Out Sheet.


The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report was reviewed and provided to Applicant Joanne Casten.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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