<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880874
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:30:18 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:SENIOR RESIDENTIAL COTTAGESFACILITY NUMBER:
331880874
ADMINISTRATOR:ALVARADO, MARGARITAFACILITY TYPE:
740
ADDRESS:16053 NIPPET LANETELEPHONE:
(909) 993-4604
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY:6CENSUS: 0DATE:
11/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Reggie FedericoTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Stephanie Torres, conducted a closure visit at the facility following verbal notification from Licensee, Margarita Alvarado, on November 05, 2021. The LPA met with Reggie Federico and informed him of the purpose of the visit.

The LPA toured the facility and did not observe any residents or personal items belonging to any residents at the facility. The LPA informed the Licensee that as of this date no elements of care and supervision are to be provided at this location unless licensure is obtained in the future. The Licensee verbalized her understanding and agreed to mail in the original license.

This report was was reviewed with the Licensee and a copy.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1