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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001441
Report Date: 03/15/2022
Date Signed: 03/15/2022 12:41:53 PM


Document Has Been Signed on 03/15/2022 12:41 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HEART OF SHADOWLANDFACILITY NUMBER:
306001441
ADMINISTRATOR:JANET SOULE'FACILITY TYPE:
740
ADDRESS:28342 SHADOWLAND CIRCLETELEPHONE:
(714) 710-9020
CITY:MODJESKA CANYONSTATE: CAZIP CODE:
92676
CAPACITY:6CENSUS: 0DATE:
03/15/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Karen FieldsTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Ruth Martinez conducted a Case Management via tele-visit due to COVID-19 and for pre-cautionary measures for the purpose to verify facility closure. LPAs spoke with Karen Fields, Administrator and discussed the purpose of the tele-visit.

LPA received renewal notice licensee no longer had interest in operating facility. LPA was informed facility closed its doors on March 15, 2021 and residents were moved out from the facility on March 01, 2021 and March 15, 2021. The administrator surrendered license by mail to Licensing. The reason for today's inspection, is to confirm the closure of the licensed facility.

LPA toured the facility via Facetime and observed no residents in care. LPA observed the home to be empty and found no evidence the home is operating as a licensed facility. Based on observation, the facility is no longer operating as a licensed facility and is closed.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with facility representative via tele-visit and a copy of this report was provided to facility representative via email. Administrator agrees to send an electronic email read receipt or response to email indicating as received as confirmation.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
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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