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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880905
Report Date: 01/28/2021
Date Signed: 01/28/2021 03:55:00 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:TEMECULA MEMORY CAREFACILITY NUMBER:
331880905
ADMINISTRATOR:GEDDIE, JAMESFACILITY TYPE:
740
ADDRESS:44280 CAMPANULA WAYTELEPHONE:
(951) 428-4990
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:64CENSUS: 5DATE:
01/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Bernadette Corpuz, Admissions & Marketing DirectorTIME COMPLETED:
03:39 PM
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Licensing Program Analyst (LPA) Deborah Mullen contacted Bernardette Corpuz, Admissions & Marketing Director to follow up on a Confirmation of Removal Notification. LPA conducted a tele-visit due to Covid 19 restrictions.

An Immediate Action Required letter dated 1/8/21 was generated to notify the licensee that Edward Crenshaw was denied a Criminal Record Clearance and that he cannot work or be present in the facility unless a Criminal Record Exemption is granted. LPA Mullen was informed that Mr. Crenshaw was an applicant but that he was never hired as an employee of the company. A signed Confirmation of Removal was received from Azizi Baranauskas, Resident Care Director, on 1/25/21.

A copy of this report was reviewed with and emailed to Ms. Corpuz for her review and signature.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
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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