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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881135
Report Date: 11/06/2023
Date Signed: 11/06/2023 09:56:02 AM

Document Has Been Signed on 11/06/2023 09:56 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:RISING STAR CARE HOME LLCFACILITY NUMBER:
331881135
ADMINISTRATOR:REED, JAMES E.FACILITY TYPE:
740
ADDRESS:40600 CHANTEMAR WYTELEPHONE:
(951) 506-4002
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY: 6CENSUS: 4DATE:
11/06/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:James Reed, Licensee/Administrator TIME COMPLETED:
10:05 AM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a Collateral visit. The purpose of the visit was to deliver findings for a complaint #18-AS-20201229100435, that is not related/associated with this facility.

LPA was greeted and granted entry by Elaine Fontillas, Caregiver, where explained the purpose of her visit.

No heath and safety concerns were observed at the time of LPAs visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to James Reed, Licensee/Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2023
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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