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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880774
Report Date: 03/22/2021
Date Signed: 03/22/2021 05:05:39 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 MS29-26
RIVERSIDE, CA 92507
FACILITY NAME:RAINCROSS AT RIVERSIDEFACILITY NUMBER:
331880774
ADMINISTRATOR:BROWN, TERRYFACILITY TYPE:
740
ADDRESS:5232 CENTRAL AVENUETELEPHONE:
(951) 785-1200
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:120CENSUS: DATE:
03/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Administrator Janet MedranoTIME COMPLETED:
05:30 PM
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On 3/22/21 Licensing Program Analyst (LPA), Shaunte Henry, conducted an unannounced health and safety check for Resident 1 (R1). R1 sustained an unwitnessed fall on 3/18/21, which resulted in a head injury. R1 is currently admitted to the hospital for their injury. LPA Henry did not observe any health and safety concerns at this time.

An exit interview was conducted where this report was provided to administrator Janet Medrano.
SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021
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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