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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201256
Report Date: 04/20/2023
Date Signed: 04/20/2023 11:28:23 AM


Document Has Been Signed on 04/20/2023 11:28 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:A LOVING HOMEFACILITY NUMBER:
079201256
ADMINISTRATOR:ALOOT, DONNIEFACILITY TYPE:
740
ADDRESS:3420 CLAYBURN RD.TELEPHONE:
(951) 522-1228
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 0DATE:
04/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Donnie Aloot, ApplicantTIME COMPLETED:
11:25 AM
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During the pre-licensing inspection on 04/20/23, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Component lll presentation with applicant.

During the Component lll presentation, LPA provided applicant information on how to operate the facility within Title 22 regulatory compliance as well as how to avoid common problem areas. Applicant confirmed understanding of regulations discussed and agreed to comply with Title 22 regulations.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
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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