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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800424
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:25:10 PM

Document Has Been Signed on 03/22/2022 02:25 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
, CA 92507
FACILITY NAME:EASTVALE SENIOR HOME CARE IIFACILITY NUMBER:
331800424
ADMINISTRATOR:BADILLA, ADELAIDAFACILITY TYPE:
740
ADDRESS:14318 PINTAIL LOOPTELEPHONE:
(951) 220-7354
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 4DATE:
03/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH: Nenita Gorospe, CaregiverTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Amy Goldenberg and Rayshaun Nickolas arrived to the facility unannounced to conduct a Plan of Correction (POC) visit. On 03/15/2022 LPA issued a deficiency for a Fire Clearance violation, section cited 87202(a). The facility had failed to meet this requirement of the section cited as evidenced by LPA observation of a makeshift sleeping quarters located in the garage are of the facility. Licensee was to remove the discussed furniture from all areas of the facility not approved for sleeping quarters as designated in their approved fire clearance by POC due date of 01/16/2022. LPAs arrived to the facility on this date to determine if the POC had been completed. LPAs observed on this date that the correction has been made and that the plan of correction has been met.

This report was reviewed with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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