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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880933
Report Date: 07/20/2022
Date Signed: 08/05/2022 10:56:47 AM


Document Has Been Signed on 08/05/2022 10:56 AM - 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:APPLE BLOSSOM RANCH ASSISTED LIVINGFACILITY NUMBER:
331880933
ADMINISTRATOR:REYNOLDS, JEREMYFACILITY TYPE:
740
ADDRESS:15651 CECIL AVE.TELEPHONE:
(951) 505-6058
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY:6CENSUS: DATE:
07/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:NoneTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannouncd for the purpose of conducting the Annual Inspection and following up on possible facility closure. LPA Colvin unable to gain entry or speak with anyone at the property as the gate surrounding the property was locked. No vehicles spotted on the property or in front of gate. LPA Colvin attempted to contact the phone number for the facility but was unable to get a hold of anyone. A copy of this report and Closure Letter will be mailed to the Licensee to document the facility closure.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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