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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880668
Report Date: 03/24/2023
Date Signed: 03/24/2023 09:28:47 AM


Document Has Been Signed on 03/24/2023 09:28 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SILVER MOON ASSISTED LIVING 2FACILITY NUMBER:
331880668
ADMINISTRATOR:HOBBS, ANGELINEFACILITY TYPE:
740
ADDRESS:35543 ATHENA CTTELEPHONE:
(951) 325-8291
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 0DATE:
03/24/2023
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Angeline Hobbs- LicenseeTIME COMPLETED:
09:37 AM
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Licensing Program Analyst (LPA) Ryan Gardner made an announced visit for the purpose of the facility's closure. LPA was met by Licensee Angeline Hobbs.

Licensee contacted LPA in reference to the closure of the facility. Licensee informed LPA that there were no residents living in the facility. LPA inspected the facility which included the bedrooms, bathrooms, dining area, kitchen, backyard, and garage.

LPA confirmed there were no residents present, and there are no personal belongings for any resident. Licensee stated the reason for closure was no longer having interest in operating a facility. Licensee stated the last resident to live at the facility was relocated to another facility on 12/1/2020. There have not been any new residents since the last resident left the facility. The effective date of closure is 3/24/23.

Licensee produced their original license to be returned to the department. An exit interview was conducted, and a copy of this report was discussed with and provided to Licensee Angeline Hobbs..
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
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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