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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881082
Report Date: 11/15/2021
Date Signed: 11/15/2021 01:45:27 PM

Document Has Been Signed on 11/15/2021 01:45 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
RIVERSIDE, CA 92507
FACILITY NAME:CALIMESA HOME CAREFACILITY NUMBER:
331881082
ADMINISTRATOR:CORPIN, DAVID P. JRFACILITY TYPE:
740
ADDRESS:220 COUNTRY CLUB DRIVETELEPHONE:
(909) 800-7906
CITY:CALIMESASTATE: CAZIP CODE:
92320
CAPACITY: 2CENSUS: 0DATE:
11/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Mildred Corpin, Assistant AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to the facility to conduct a case management visit. The purpose of this visit is to assess facility for substantial compliance in response to receiving a hospice waiver for two residents. This facility does not currently have any residents in care but are fire cleared for two residents, two of which may be bedridden.

During this visit LPA toured the facility and observed that all the precautionary physical plant measures are in place for dementia care and did not observe any non compliance issues precluding the issuance of hospice waiver. In addition, LPA provided technical assistance in the areas of care of persons with dementia, training requirements if advertising dementia special care and provided copies of the regulations 87705, 87706 87707.

LPA has found the facility is in substantial compliance and there are no deficiencies being issued per Title 22, Division 6, of the California Code of Regulations.

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: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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