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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880746
Report Date: 03/17/2021
Date Signed: 03/22/2021 11:46:46 AM

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:NIGHTINGALE CARE ASSISTED LIVINGFACILITY NUMBER:
331880746
ADMINISTRATOR:JUNG, LEENEFACILITY TYPE:
740
ADDRESS:13843 PEYTON DRIVETELEPHONE:
(909) 549-5857
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 0DATE:
03/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Leene JungTIME COMPLETED:
11:08 AM
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Licensing Program Analyst (LPA) Jennifer Semin contacted the licensee, Leene Jung via FaceTime to verify closure of the facility. LPA observed all bedrooms, bathrooms, living room and kitchen to verify no residents were present. Ms. Jung stated she had only 1 resident and they have been relocated to another licensed facility.
Ms. Jung stated she placed the license in the mail to 1650 Spruce St. Ste 200 Riverside CA 92507 on 3/09/2021.

The facility is closed as of today's date 3/17/2021.

An exit interview was conducted with the administrator via telephone and a copy of this report was provided via email.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021
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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