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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880895
Report Date: 10/28/2021
Date Signed: 11/10/2021 10:53:34 AM

Document Has Been Signed on 11/10/2021 10:53 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ATTENTIVE MANOR IIFACILITY NUMBER:
331880895
ADMINISTRATOR:PECK, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:31221 EL TORO RDTELEPHONE:
(760) 620-5915
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 5DATE:
10/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Gabriel Boudet, CNATIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted a case management visit to the facility. LPA met with Certified Nursing Assistant Gabriel Boudet and explain the purpose of the visit. During the visit, LPA spoke to Administrator Matthew Siegel by telephone and confirmed Attentive Manor (336426470) has no residents in placement. Mr. Siegel referred LPA to Administrator Christopher Peck for further assistance to obtain the requested documentation regarding a complaint control # 18-AS-20200529135656 at Attentive Manor (336426470). LPA spoke with Mr. Peck by telephone and arranged to have the requested documents emailed to LPA by the end of the day.

An exit interview was conducted, and a copy of this report was reviewed and left with Mr. Boudet.

*****This is an Amended Report********
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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