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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427578
Report Date: 02/16/2023
Date Signed: 02/16/2023 12:44:11 PM

Document Has Been Signed on 02/16/2023 12:44 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:FOOTHILL LAKE HOMEFACILITY NUMBER:
336427578
ADMINISTRATOR:ANGELITO V. MENDOZAFACILITY TYPE:
740
ADDRESS:24746 MORNING MIST DRIVETELEPHONE:
(951) 208-1722
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 3DATE:
02/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Julita Mendoza, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an investigation into a complaint (18-AS-20230210115209). LPA met with caregiver Evelyn Manuel. Administrator Julita Mendoza arrived while conducting the visit. During the the tour of the facility, LPA noted these described deficiencies:

1. Door to Room #1 is coming apart at the hinges, and does not completely close.

2. Sliding closet is completely off the railing in Room #5.

An exit interview was conducted where a copy of this report was provided along with a copies of the LIC809-D, and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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
Document Has Been Signed on 02/16/2023 12:44 PM - It Cannot Be Edited


Created By: Jesse Gardner On 02/16/2023 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FOOTHILL LAKE HOME
FACILITY NUMBER: 336427578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
87303

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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not being provided as evidenced by:
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Licensee agrees to repair the closet in Room #5, and the door to Room #1, and provide proof of such to LPA by POC date.
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Based on LPA's observation, Licensee did not adhere to the regulation by the sliding closet door in Room #5 being off of the railing, as well as the door to Room #1 loose from the door frame. This presents a potential health and safety and or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023


LIC809 (FAS) - (06/04)
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