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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426468
Report Date: 10/03/2024
Date Signed: 02/03/2025 12:28:20 PM

Document Has Been Signed on 02/03/2025 12:28 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
RIVERSIDE, CA 92507
FACILITY NAME:FAMILYCARE HOME - MONTARAFACILITY NUMBER:
336426468
ADMINISTRATOR/
DIRECTOR:		JOSE KOFACILITY TYPE:
740
ADDRESS:9781 VIA MONTARATELEPHONE:
(951) 924-0181
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 4DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:19 PM
MET WITH:ADMINISTRATOR, DEXTER KOTIME VISIT/
INSPECTION COMPLETED:
03:08 PM
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On October 03, 2024, Licensing Program Analysts (LPAs), Venus Mixson, and Yolanda Delgado made an unannounced visit to the facility for the purpose of conducting the Required Annual inspection, and met with Administrator, Dexter Ko and introduced themselves and stated the purpose for the visit.
Infection Control: LPAs observed the hand washing stations in the facility restrooms. LPAs observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPAs reviewed the facility's infection control plan and found all required infection control measures met.
PHYSICAL PLANT: Facility is licensed for four and is operating at 100 % capacity of four which is within the conditions and limitations of the license. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to Administrator, there are no known weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. Temperature was within in regulations for this time of day and the season. There was sufficient lighting throughout the facility and the Hot water tested within regulations at 107.5 degrees F. Fire extinguisher located in hall area has proper inspection tag and was inspected 09/18/2024. The smoke and carbon monoxide alarms were in the green and last inspected on today and were operable. The interior and exterior areas of the home were observed to be clean and organized.
FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean. LPAs observed the required two-day supply of perishable and seven-day supply of non-perishable foods.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
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
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
RIVERSIDE, CA 92507
FACILITY NAME: FAMILYCARE HOME - MONTARA
FACILITY NUMBER: 336426468
VISIT DATE: 10/03/2024
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Care & Supervision/Administration: Adequate staffs are present for the supervision of residents in care, two at present and the Administrator arrived shortly after. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses an administrator certificate that they have paid for a renewal as the expiration date was 09/13/2022.

Record Review and Resident/Staff Files: LPAs reviewed staff files and reviewed the facility's staff schedule. Staff files reviewed have criminal clearance and updated training along with CPR/First Aid Certification. Four client files were reviewed and possessed required paperwork.



MEDICATION: Medications were reviewed for residents in care and medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care. Medications and medication documentation was observed to be well organized and monitored.

Disaster preparedness: LPAs reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA's observed the last fire drill was conducted on 09/02/2024, and met the department standards.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.



An exit interview was conducted where a copy of this report was provided to administrator, Dexter Ko.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
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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