<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
331880894
Report Date:
12/09/2021
Date Signed:
12/09/2021 03:23:55 PM
Document Has Been Signed on
12/09/2021 03:23 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
RIVERSIDE
,
CA
92507
FACILITY NAME:
PLEASANT WAYS ADULT RESIDENTIAL
FACILITY NUMBER:
331880894
ADMINISTRATOR:
WALKER, KEITH
FACILITY TYPE:
735
ADDRESS:
761 AMOR DR.
TELEPHONE:
(951) 312-1751
CITY:
SAN JACINTO
STATE:
CA
ZIP CODE:
92582
CAPACITY:
4
CENSUS:
2
DATE:
12/09/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:00 PM
MET WITH:
Kevin Walker
TIME COMPLETED:
03:30 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) Javier Prieto arrived to the facility to sign amended complaint investigation report
(18-AS-20210308084951)
initially signed on 03/09/2021. Findings of the investigation remain as unsubstantiated.
SUPERVISORS NAME
:
Karen Clemons
LICENSING EVALUATOR NAME
:
Javier Prieto
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/09/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/09/2021
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