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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880633
Report Date: 09/01/2023
Date Signed: 09/01/2023 03:54:34 PM


Document Has Been Signed on 09/01/2023 03:54 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:CALIFORNIA MANOR GUEST HOME #1FACILITY NUMBER:
331880633
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:8536 & 8548 CALIFORNIA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:12CENSUS: 12DATE:
09/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff, Ahamed AbdallatefTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit for the purpose of an unrelated complaint. This report is to document items observed during the visit. The LPA met with Staff, Ahamed Abdallatef who was informed of the purpose of the visit.

LPA interviewed staff and residents and it was found that R1 did not have a key to their room. The staff stated they would provide a key to R1 by tomorrow 9/2/2023 and provide the R1 with a copy of their key. LPA documented technical advisory note and staff agreed to send LPA a photo of when this is conducted. Failure to provide such proof may result in citations to the facility.

An exit interview was conducted with Staff, Ahamed Abdallatef where this report was reviewed and provided to them.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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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