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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881077
Report Date: 04/21/2022
Date Signed: 04/21/2022 12:57:11 PM


Document Has Been Signed on 04/21/2022 12:57 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
, CA 92507



FACILITY NAME:SEA BREEZE HOMES OF EASTVALE LLCFACILITY NUMBER:
331881077
ADMINISTRATOR:LONG, MARIAM BFACILITY TYPE:
740
ADDRESS:5897 SPRINGCREST STTELEPHONE:
(714) 299-9634
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 4DATE:
04/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Miriam Long, AdministratorTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility to conduct a Plan of Correction visit. The licensee was issued a deficiency for a violation of the fire clearance on 04/20/22, based on LPA observation of a makeshift living/sleeping quarters located in the garage. LPA toured the garage area and observed that the Plan of Correction has been met and the immediate risk to health and safety has been abolished. This report was reviewed with and a copy was provided to the facility representative
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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