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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880585
Report Date: 05/22/2024
Date Signed: 05/22/2024 01:01:25 PM


Document Has Been Signed on 05/22/2024 01:01 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:COOL MEADOW CAREFACILITY NUMBER:
331880585
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:29787 COOL MEADOW DRTELEPHONE:
(951) 246-0214
CITY:MENIFEESTATE: CAZIP CODE:
92587
CAPACITY:6CENSUS: 4DATE:
05/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Long ZhangTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit for an unrelated matter. LPA met with Licensee, Long Zhang, who was informed of the purpose of the visit.

During the visit information was revealed on past residents and employee. LPA conducted interviews and gathered records. LPA informed the licensee this investigation will remain open at this time.

An exit interview was conducted with Licensee, Long Zhang where this report, deficiency page and appeal rights were reviewed and provided to them.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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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