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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880747
Report Date: 02/28/2024
Date Signed: 02/28/2024 12:30:23 PM

Document Has Been Signed on 02/28/2024 12:30 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CHIHUAHUA HOMEFACILITY NUMBER:
331880747
ADMINISTRATOR:SHAYLA RODRIGUEZFACILITY TYPE:
735
ADDRESS:77595 CALLE CHIHUAHUATELEPHONE:
(442) 256-4174
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 4CENSUS: 3DATE:
02/28/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:House Manager, Andrea LopezTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a collateral visit for a complaint visit from SVS Palm Springs, on the health, safety, and welfare of residents in care. RIV RO, Community Care Licensing received a complaint on February 22, 2024 regarding a resident 1 (R1). LPA met with the House Manager, Andrea Lopez, to inform her of the purpose of the visit and was granted entry.

LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care. LPA conducted additional interviews with staff and residents and request pertinent documents for the collateral visit.

No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with House Manager, Andrea Lopez and a copy of this report is left with the her as evidence by her signature.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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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