335530262-12-16-2024-56-AS-MBRN-DBZRT8-20241216121757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530262
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:18:05 PM

Document Has Been Signed on 12/16/2024 12:18 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
, CA 92507

FACILITY NAME:	SOUL NEW HOPE		FACILITY NUMBER:	335530262
ADMINISTRATOR/ DIRECTOR:	MARTINEZ, ALONSO A.		FACILITY TYPE:	740
ADDRESS:	35798 RHONE LANE		TELEPHONE:	(951) 599-4369
CITY:	WINCHESTER	STATE: CA	ZIP CODE:	92596
CAPACITY: 6		CENSUS: 0	DATE:	12/16/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Applicant/Administrator Alonso Martinez		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE

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On 12/16/2024 at 09:10 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA Brown met with Applicant/Administrator Alonso Martinez. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 06/20/2024 for a total capacity of six (6) of which six (6) can be nonambulatory. Fire clearance was granted on 09/09/2024 for six (6) non-ambulatory residents. LPA Brown observed the following:

Structure:
Facility was a one (1) story house with four (4) resident bedrooms, one (1) staff bedroom and three (3) bathrooms, living room, dining area/kitchen and laundry. There was an attached two (2) car garage in front of the house.

Heating/Cooling System:
Central heating and air conditioning system installed with one (1) central panel located in the hallway to
control entire house.

Bedrooms:
Each resident bedrooms accommodate any nonambulatory residents. All resident bedrooms were adequately furnished with bed, chair, closet, dresser, appropriate linens, adequate lighting, nightstands, a lamp and an operable smoke detector.

Bathrooms:
The three (3) resident/staff bathrooms have a working toilet, wash basin, grab bars, customized flooring in the resident/staff shower and tub with an adequate supply of toilet paper and soap. LPA Brown tested the water temperatures in the staff/residents' bathrooms. ***CONTINUED ON LIC 809-C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SOUL NEW HOPE	FACILITY NUMBER: 335530262
	VISIT DATE: 12/16/2024

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***CONTINUED FROM LIC 809***
LPA Brown verified water temperature was measured at 108.3 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
were secured in a locked cabinet and locked box located in the kitchen. There was adequate room for food storage. LPA Brown observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies were observed in the laundry room that's locked and not accessible to residents. Garage door is locked away from residents.

Living Room:
There was 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 hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on right side of the house that leads
into the backyard. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted near the main entrance. There was Let-Us-No poster, Ombudsman Poster, Emergency Disaster Plan and Personal Rights observed.

Dementia Care Plan:
LPA Brown observed and reviewed the Dementia Care Plan during the visit.

General items:
One (1) fire extinguisher was charged and located in the living room. five (5) smoke detectors and two (2) carbon monoxide detectors were tested and were observed to be in ***CONTINUED ON LIC 809-C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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
, CA 92507

FACILITY NAME: SOUL NEW HOPE	FACILITY NUMBER: 335530262
	VISIT DATE: 12/16/2024

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***CONTINUED FROM LIC 809***

working order. Resident records and staff records will be stored in a locked closet in the hallway. First Aid kit with required components, First Aid Book and locked area for medication storage was observed. LPA Brown observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 951-599-4369.

There is enough Emergency water supply, and the required 72-hour emergency food supply and Emergency Supplies/Kits for residents and staffs available at the facility. Component III was completed on this day as well.

Additionally, LPA Brown observed the facility having Visitor Sign In/Sign Out Sheet and Resident Sign In/Sign Out Sheet, upon entering facility.

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 residents in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to
Applicant/Administrator Alonso Martinez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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