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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881008
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:54:37 PM


Document Has Been Signed on 07/27/2022 02:54 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:WINE COUNTRY ASSISTED LIVINGFACILITY NUMBER:
331881008
ADMINISTRATOR:SCHNEIDER, ELVIRAFACILITY TYPE:
740
ADDRESS:5 SHASTA LAKE DRTELEPHONE:
(818) 277-0403
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 6DATE:
07/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Heather Acosta, House ManagerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit for the purpose of delivering an amended report that was in relation to complaint #18-AS-20220317152020 that was originally conducted on 03/22/2022.

LPA met with House Manager Heather Acosta, and advised that the amended report is LIC9099D.

An exit interview was conducted where a copy of this report was discussed with Ms. Acosta and a copy of the amended LIC9099-D was also provided to Ms. Acosta.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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