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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530229
Report Date: 09/11/2024
Date Signed: 09/11/2024 11:16:46 AM

Document Has Been Signed on 09/11/2024 11:16 AM - 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:MJ SENIOR HOMECARE SERVICES LLCFACILITY NUMBER:
365530229
ADMINISTRATOR/
DIRECTOR:		CHANIKORNPRADIT, MABELFACILITY TYPE:
740
ADDRESS:2172 N MAGNOLIA AVENUETELEPHONE:
(917) 459-1710
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 0DATE:
09/11/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mabel Chanikornpradit, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPAs) LaVette Farlow and Michelle Echeverria , arrived at MJ Senior Homecare Services LLC, to conduct an announced Pre-Licensing visit for licensure. LPAs was greeted by licensees, Mabel Chanikompradit and Jenelle Wang. LPAs Farlow and Echeverria introduced themselves and stated the purpose of the visit. LIC200 application was submitted on 04/10/23 for (4) non-ambulatory residents and (2) bedridden residents. Fire Safety Inspection clearance was granted for (4) non-ambulatory residents and (2) bedridden residents on 07/02/24. LPAs toured the facility inside and outside and observed the following:

Structure: Facility is a one story house with (4) resident bedrooms, (2) resident bathrooms, office/staff area, living room, dining area, kitchen, pantry, backyard, and attached garage.

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

Bedrooms: One bedroom accommodates two non-ambulatory residents, two bedrooms accommodates one non-ambulatory resident in each room, and one bedroom accommodates two bedridden residents on the far left side of the house.

Bathrooms: The resident bathrooms have grab bars, working toilet, wash basin, and shower with an adequate supply of toilet paper and soap.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent, and chemicals are stored in locked cabinets/office. There was a pantry stocked with non-perishable food and perishable food found in the refrigerator. LPAs observed the stove to be operational. Refrigerator/freezer were in working condition. Water tested in the bathroom faucet measured at 112.2 degrees fahrenheit. A functional washer and dryer are located inside the garage.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MJ SENIOR HOMECARE SERVICES LLC
FACILITY NUMBER: 365530229
VISIT DATE: 09/11/2024
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Living/Family room: There was a furnished living room with reading books and a tv observed.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies stored in a closet.

Yards/Outside: There is an enclosed Koi Pond, fruit trees, a shaded patio with seating area, two sheds on the left side of the house and a self-latching handle gate on the left side and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions. There are no firearms, ammunition, swimming pool on the grounds.

Emergency Phone Numbers, and Exit Plan: Facility sketch, visiting rules, and personal rights were observed posted by the hallway/entrance.

General items: The smoke and carbon monoxide detectors were tested and are operable. There was two fully charged fire extinguishers observed. Resident/Staff records stored inside the locked office. First Aid kit with required components, and a locked area for medication storage was observed.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. LPAs completed COMP III with the Licensee at the conclusion of the inspection.

Licensees will be notified once facility is licensed. An exit interview was conducted, and this report was discussed and provided to licensees, Mabel Chanikornpradit and Jenelle Wang
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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