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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426029
Report Date: 02/27/2025
Date Signed: 02/27/2025 12:39:18 PM

Document Has Been Signed on 02/27/2025 12:39 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CALOAKS SENIOR LIVINGFACILITY NUMBER:
336426029
ADMINISTRATOR/
DIRECTOR:
AMELIA ALADINFACILITY TYPE:
740
ADDRESS:3891 POLK STREETTELEPHONE:
(951) 689-6162
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 74CENSUS: 57DATE:
02/27/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH: Licensee/Administrator Amelia AladinTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 02/27/2025 at 08:45 AM, Licensing Program Analysts (LPAs) Melody Brown and Beena Singh conducted an unannounced visit at this location to commence a health and safety check. LPAs Brown and Singh identified themselves and discussed the purpose of the visit with Licensee/Administrator Amelia Aladin due to the incident that occurred at the facility on 10/22/2024 reported in Unusual Incident Report (LIC624 ) received regarding Resident #1 (R1) aggressive behavior to Resident #2 (R2).

Licensee/Administrator Aladin informed LPAs that R1 was served 30 Day Eviction Notice and moved out on 10/30/2024. Interviews with six (6) of six (6) staffs indicated that they are providing care and supervision to all their residents. Six (6) of six (6) staff interviews revealed that they are checking on their residents every 30 minutes. During the facility visit today, LPAs observed staffs doing their rounds and checking on their residents. LPAs were provided R1’s medical records and per review, R1 did not sustain injuries from the reported incident.

LPAs conducted a quick tour of the facility. Residents in care were present during the visit. No imminent health and/or safety concerns observed at the time of visit. LPAs observed no health and/or safety hazards at this location. LPAs inspected the outside perimeter at this location and observed no health and/or safety hazards. LPAs observed sufficient staff present at this location to provide care and supervision. LPAs inspected the food supplies at this location and observed an adequate supply of perishable and 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 Licensee/Administrator Amelia Aladin.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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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