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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881544
Report Date: 10/15/2024
Date Signed: 10/15/2024 09:22:02 AM

Document Has Been Signed on 10/15/2024 09:22 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:MORENO BEACH HOUSE OF CAREFACILITY NUMBER:
331881544
ADMINISTRATOR/
DIRECTOR:		CHEN, JOHNFACILITY TYPE:
740
ADDRESS:27765 SOLITUDE AVENUETELEPHONE:
(949) 441-9833
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 0DATE:
10/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Angelica Ubungen, licenseeTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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The Department received a notice from the Licensee of a fire clearance change request on 05/13/2024. The Licensee reported the request would be submitted to change the fire clearance from six (6) ambulatory residents to six (6) non-ambulatory residents. An inspection of the facility was completed on the above date. The LPAs inspected the interior and exterior areas of the home. The home appeared to be adequately maintained for the care of non-ambulatory residents. No health and safety concerns were observed at the time of the inspection.

An exit interview was conducted and this report was reviewed with Angelica Ubungen, licensee, and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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