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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604137
Report Date: 03/03/2025
Date Signed: 03/03/2025 01:49:02 PM

Document Has Been Signed on 03/03/2025 01:49 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:AFFIRMATIVE'S ELITE HOMEFACILITY NUMBER:
374604137
ADMINISTRATOR/
DIRECTOR:
SHAH, DEENAFACILITY TYPE:
740
ADDRESS:1729 SUMMIT DRTELEPHONE:
(760) 294-0357
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 4DATE:
03/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Ronni Haragos, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required inspection. LPA was greeted and granted entry by Caregiver Ronni Haragos, where LPA explained the purpose of the visit. At the time of the visit there was (2) staff (4) residents present. The facility has an approved hospice waiver for (5), with there currently being (4) residents that are receiving services.

The medications were observed to be locked inside a cabinet located in the kitchen in between the refrigerator and double stacked ovens. There were no pools or bodies of water observed on the premises. There are no known guns or ammunition stored on grounds. The sharps were observed to be locked and inaccessible to residents in care.

The emergency drills are conducted on a monthly basis, the last drill was conducted on 01/05/25. The hot water tested in the resident bathrooms and were observed to be within regulatory limits measuring at 113 degrees Fahrenheit. The governing body is active and is in good standing, and the annual fees that were due have been paid.

The facility was observed to have a two day supply of perishable and a seven day supply of non perishable food items.

LPA conducted a records review of both staff and resident files and found to be complete with the required forms. The facility has the required postings posted throughout the facility.

Based on today's visit there were no deficiencies cited. An exit interview was conducted and a copy of the LIC 811-Confidential names list, was reviewed and provided to Caregiver Ronni Haragos
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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