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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880767
Report Date: 09/23/2020
Date Signed: 09/23/2020 04:16:35 PM

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:EVERWOOD HOME CARE LLCFACILITY NUMBER:
331880767
ADMINISTRATOR:MEKAIL, KYROLLOSFACILITY TYPE:
740
ADDRESS:13247 YELLOWWOOD STREETTELEPHONE:
(951) 750-9207
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 0DATE:
09/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:New home ownerTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Javier Prieto made a case management visit to the facility to confirm that facility is no longer operating as a licensing facility. Licensee Kyrollos Mekail spoke notified Licensing that he will longer be operating home as a licensed facility. Mekail also stated that since facility has been licensed in October of 2019, the facility has not had any clients residing at the facility and that the home was sold and the new owner took ownership of the residence on September 1, 2020. Mekail stated that he does not reside at the facility, own the home or have any clients residing at the residence.

LPA Prieto arrived to the facility location, knocked on door and male (did not give name) answered. LPA stated his name and reason for visit. LPA stated that the home was a licensed facility and owner gave up license once the home was sold on September 1st of this year. Male owner stated that that is true. LPA asked if the home was operating as a licensed or unlicensed facility or if there are any clients in the home. Male owner stated the home is not a licensed facility nor are the caring for any clients.

Licensee was not available to to sign this document, but confirmed that visit will be made to observe that licensee is not longer residing at residents and that the residence is not operating as a licensed facility and not caring for any clients,
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020
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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