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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402994
Report Date: 04/08/2022
Date Signed: 04/08/2022 10:24:51 AM

Document Has Been Signed on 04/08/2022 10:24 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
, CA 92507
FACILITY NAME:LIFESTYLE HOME CAREFACILITY NUMBER:
336402994
ADMINISTRATOR:MARY MATEASFACILITY TYPE:
740
ADDRESS:5377 CAROL WAYTELEPHONE:
(951) 684-5833
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY: 6CENSUS: 3DATE:
04/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Maria MatiasTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 04/08/2022 at 08:45 AM to commence a health and safety check. LPA Brown identified herself and discussed the purpose of the visit with Staff 1. Administrator Maria Matias was contacted and arrived at the facility and LPA Brown explained the purpose of the visit due to complaint # 56-AS-20220407125449.

Residents in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA Brown observed no health and/or safety hazards inside the facility. LPA Brown inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Brown observed sufficient staff present at the facility to provide care. LPA Brown inspected facility food supplies and observed three (3) days supply of perishable and seven days (7) supply of non-perishable food. The needs of the residents in care appear to be met during this inspection.

An exit interview was conducted where this report (LIC809) was discussed and provided to Administrator Maria Matias.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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