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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427577
Report Date: 06/15/2023
Date Signed: 06/15/2023 01:14:47 PM

Document Has Been Signed on 06/15/2023 01:14 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CANYON LAKE TERRACEFACILITY NUMBER:
336427577
ADMINISTRATOR:JULITA MENDOZAFACILITY TYPE:
740
ADDRESS:30701 EMPEROR DRIVETELEPHONE:
(951) 244-1958
CITY:CANYON LAKESTATE: CAZIP CODE:
92587
CAPACITY: 6CENSUS: 6DATE:
06/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Julita Mendoza, LicenseeTIME COMPLETED:
01:10 PM
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On June 15, 2023, Licensed Program Analyst (LPA) Jacqueline Shaw Ross met with Licensee, Julita Mendoza at her facility, Canyon Lake Terrace. The purpose of the visit was to deliver the findings for complaint investigation #18-AS-20230519141105, at Licensee's other facility, Foothill Lake Home. Licensee informed LPA that Foothill Lake Home has been temporarily closed as of June 3, 2023 for major renovations and residents have been moved to this location temporarily. Findings were delivered and information was recorded under Foothill Lake Home.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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