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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881428
Report Date: 09/08/2023
Date Signed: 09/08/2023 11:42:44 AM

Document Has Been Signed on 09/08/2023 11:42 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MOTHER DOLOROSA HOME CAREFACILITY NUMBER:
371881428
ADMINISTRATOR:RAMIREZ, JOSE RICARDO L.FACILITY TYPE:
740
ADDRESS:29533 MACTAN ROADTELEPHONE:
(858) 610-4098
CITY:VALLEY CENTERSTATE: CAZIP CODE:
92082
CAPACITY: 6CENSUS: 0DATE:
09/08/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Applicant Jose Ramirez TIME COMPLETED:
12:00 PM
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On 9/8/2023, Licensing Program Analyst (LPA) Janette Romero conducted an announced visit to the pending facility to conduct a pre-licensing inspection. LPA met with Applicant Jose Ramirez. Fire clearance has been granted for six (6) elderly residents. Applicant Ramirez’s Administrator certificate expires on 10/21/2023.

LPA conducted of a tour of the facility’s interior and exterior. The facility is made up of a one-story home with three (3) resident bedrooms, two (2) resident bathrooms, a kitchen, living/family room, storage room and laundry room. LPA did not observe bodies of water on the premises. The physical plant is in good repair. Indoor and outdoor passageways are free of obstruction. An outdoor shaded seating area is available for future residents. LPA observed a charged fire extinguisher mounted in the dining room wall. LPA tested the smoke alarms and carbon monoxide detectors and found them to be operational. The facility also has a working telephone. LPA observed a locked cabinet for resident and staff files and centrally stored medications. Cleaning solutions and knives/sharp instruments will be secured in a kitchen cabinet.

Resident bedrooms had the required bedding, furniture, closet storage, and functional lighting. Additional linen and towels are available for future residents. LPA toured the kitchen and observed that food was stored in a safe and healthful manner. The facility had a 2-day supply of perishable food items and 7-day supply of nonperishable food items. LPA observed emergency food and water in the storage room. Bathrooms were equipped with a grab bar near the toilet and in the shower. The hot water temperature in the resident bathrooms measured to 118-degrees Fahrenheit.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MOTHER DOLOROSA HOME CARE
FACILITY NUMBER: 371881428
VISIT DATE: 09/08/2023
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Continued from LIC809..

Living/family room has a working television and adequate seating in common areas. The facility has a split heating and air conditioning system installed in each resident room to allow residents to control their room temperatures. Emergency disaster plans, personal rights, and complaint procedures were posted in living/family room wall. LPA observed two (2) complete first aid kits.

During today’s visit, LPA did not observe any issues or concerns.



Applicant Ramirez is scheduled to complete the Comp III on Tuesday, 9/12/2023, at 9:00 a.m., at the Riverside Regional Office. Final approval of licensure will be granted by the Centralized Application Bureau analyst.

An exit interview was conducted where a copy of this report was discussed and provided to Applicant Ramirez.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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