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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880860
Report Date: 02/24/2025
Date Signed: 02/24/2025 04:18:32 PM

Document Has Been Signed on 02/24/2025 04:18 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALPHALIFE HOMECAREFACILITY NUMBER:
361880860
ADMINISTRATOR/
DIRECTOR:
SALDIVAR, BRYANT JFACILITY TYPE:
740
ADDRESS:9154 BELLFAST ROADTELEPHONE:
(909) 601-5154
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 12CENSUS: 3DATE:
02/24/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Marlon Borja & Yanira SalvidarTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On February 24, 2025, the Department held an informal office meeting to discuss the death of the Licensee and the status of the facility’s license. On 12/13/2024, the regional office was informed of the death of the licensee. In attendance was Licensing Program Manager (LPM) Karen Clemons, Licensing program Analyst (LPA), Magda Malcore and facility representatives Marlon Borja and Yanira Saldivar.

During today's meeting the following was discussed: date of licensee’s passing was on September 13, 2024. The family expressed they wish to continue the operation of the facility. Yanira Saldivar is currently overseeing the facility. The facility has a current census of three (3) residents in care and there are no residents on Hospice. The new facility Administrator Marlon Borja has a pending administrator certification. Current staff working have criminal record clearances through the Department.

The facility representatives agreed to provide the following to the regional office: proof of death documentation, client/resident registry, and personnel report (LIC500) by February 25, 2025. The facility representatives have also agreed not to accept new residents until new license has been issued.

The facility representatives will submit an application for licensure by February 26, 2025, to Centralized Application Bureau (CAB), 744 P Street, MS 9-14-8201, Sacramento, CA 95814.

Upon receipt of all requested documents and application submittal, the Department will review for Emergency Approval to Operate form.

An exit interview was conducted with the facility representatives and a copy provided at the conclusion of the meeting.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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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