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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408630
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:05:30 PM

Document Has Been Signed on 09/25/2024 04:05 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:HAZEL GUEST HOME IIFACILITY NUMBER:
336408630
ADMINISTRATOR/
DIRECTOR:		HAZEL A. BUTARDOFACILITY TYPE:
740
ADDRESS:24629 SUPERIOR AVENUETELEPHONE:
(951) 247-9355
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Administrator, Hazel AbellaTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to conduct an annual required visit. LPA was greeted and granted entry by Caregiver, Myrna de Jesus who was informed of the purpose of visit. LPA met with Licensee Hazel Abella shortly after who provided records. During the visit, there was (2) residents and (3) staff present. (1) client is currently in the hospital.

There are (5) bedroom and (2) bathrooms. (4) bedrooms are for residents and (1) staff room. No pools or fire arms are located at the facility.

The facility has an infection control plan and training on file which meets the department requirements. No current resident has infectious diseases. LPA observed hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical plant was observed which was clean and orderly. Required fixtures, furniture, linens and working utilities were found in the facility. Hot water temperature was read at 114.6F. The outdoor area is free of hazards and has a shaded area for residents. The kitchen was observed to be sanitary. Required food supplies were observed. Activities, schedule, menu and required postings were found in the facility. Appliances in kitchen and laundry room are in working condition.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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: HAZEL GUEST HOME II
FACILITY NUMBER: 336408630
VISIT DATE: 09/25/2024
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Medications were secured in a locked cabinet. LPA reviewed physical medications for (2) residents as well as the Medication Administration Record (MAR) log. No discrepancies were found.

All staff on schedule are fingerprint cleared. LPA reviewed (4) staff files and (3) client records which posses required paperwork. The current administrator was available present during the visit and has proof of submitting renewal certification. The facility has proof of current liability insurance. Annual fees are up to date and contact information was reviewed with the licensee.

The facility's last conducted fire drill was documented 8/11/2024. The emergency and disaster plan is posted at the facility. Emergency supplies, charged fire extinguisher and first aide kit are present. The exits were observed to be free of obstructions.

No deficiencies were cited at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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