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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530060
Report Date: 03/18/2025
Date Signed: 03/18/2025 12:34:31 PM

Document Has Been Signed on 03/18/2025 12:34 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:SELENA SENIOR HOME LLCFACILITY NUMBER:
365530060
ADMINISTRATOR/
DIRECTOR:		HUSSEIN, SHADENFACILITY TYPE:
740
ADDRESS:9713 EUGENIA AVETELEPHONE:
(205) 777-9144
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 4DATE:
03/18/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:51 AM
MET WITH:Shaden HusseinTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to conduct a case management visit. Upon arrival, LPA met with Facility Administrator Shaden Hussein. On 2/13/2025, the Licensee received an approved fire clearance from San Bernardino County Fire Department for one (1) approved bedridden. Capacity of 6 will remain the same. LPA will update the facility's file and issue a new license stating the change for the approval of one (1) bedridden only and five (5) ambulatory only.

An exit interview was conducted where this report LIC809 was discussed and provided to Facility Administrator Shaden Hussein at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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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