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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881212
Report Date: 12/13/2022
Date Signed: 12/13/2022 12:04:25 PM

Document Has Been Signed on 12/13/2022 12:04 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:DELICARE HEALTH SERVICESFACILITY NUMBER:
331881212
ADMINISTRATOR:AWAD, SAMEHFACILITY TYPE:
740
ADDRESS:31416 CHEMIN CHEVALIERTELEPHONE:
(909) 559-7200
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY: 6CENSUS: 5DATE:
12/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Sameh Awad, Licensee TIME COMPLETED:
12:15 PM
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On December 13, 2022, Licensing Program Analyst (LPA) Chinwe Nwogene made an unannounced visit to follow up on information reported to the Department regarding Resident One (R1).

LPA toured the facility, conducted interviews with resident and staff, reviewed resident’s file and collected copies of pertinent document.

An exit interview was conducted where a copy of this report was discussed with and provided to Licensee, Sameh Awad.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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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