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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880838
Report Date: 12/07/2023
Date Signed: 12/07/2023 05:24:38 PM


Document Has Been Signed on 12/07/2023 05:24 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:EMK RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
331880838
ADMINISTRATOR:PANALIGAN, MARILOUFACILITY TYPE:
740
ADDRESS:7750 BOLERO DRIVETELEPHONE:
(951) 332-0558
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: 6DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Christian, TIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Javier Prieto and LPA Anna Buena arrive to the facility to conduct an unannounced annual inspection. LPA's were greeted by staff Christian See and allowed entry. Inspection consisted of file review, staff interviews, documentation and facility tour. Due to time restraints a continuation of this inspection is needed.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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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