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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880617
Report Date: 07/22/2022
Date Signed: 08/31/2022 03:53:03 PM

Document Has Been Signed on 08/31/2022 03:53 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOLDEN EYE RESIDENTIAL CAREFACILITY NUMBER:
331880617
ADMINISTRATOR:JACKSON, WILLIAMFACILITY TYPE:
735
ADDRESS:23066 GOLDEN EYE LNTELEPHONE:
(951) 907-6092
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 0DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:William Jackson, LicenseeTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Stephanie Torres, made an announced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA met with Licensee, William Jackson, and informed him of the purpose of the visit. There are currently no clients in care.

The LPA toured the facility and observed no clients in care. Per Jackson, the home is pending vendorization through Inland Regional Center (IRC).

The LPA advised Jackson to ensure the Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report is reviewed and COVID-19 guidelines are put into place prior to the admission of any clients into the home. The LPA advised Jackson to contact the Regional Office when one or more clients are admitted in order for the Department to conduct a follow up visit to the home to ensure compliance with state regulation and COVID-19 guidance. Jackson verbalized his understanding.

This report was reviewed with Jackson and a copy was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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