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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881082
Report Date: 03/29/2021
Date Signed: 03/29/2021 09:20:53 AM

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:CALIMESA HOME CAREFACILITY NUMBER:
331881082
ADMINISTRATOR:CORPIN, DAVID P. JRFACILITY TYPE:
740
ADDRESS:220 COUNTRY CLUB DRIVETELEPHONE:
(909) 800-7906
CITY:CALIMESASTATE: CAZIP CODE:
92320
CAPACITY:2CENSUS: 0DATE:
03/29/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:David Corpin, AdministratorTIME COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Tricia Danielson conducted this second pre-license visit on this day with Administrator (AD) David Corpin. A second visit was required to verify the corrections of items needed as identified during the initial pre-licensing inspection.
LPA observed the facility side gate to have a spring attached and now operates in a self latching manner. LPA also observed covered patio seating which will accommodate all residents in care. Also, LPA observed all cleaning supplies to be removed from areas which residents may have access and have now been secured. LPA verified the facility now has the required 72 hour emergency food supply. LPA spoke with a representative of the Ombudsman office who will have an Ombudsman poster delivered to the facility.

Based on todays inspection, the items identified during the initial pre-licensing visit have been resolved and the pre-licensing has now been completed. Final approval of licensure will be granted by the Centralized Application Bureau (CAB) analyst.

An exit interview was conducted and a copy of this report was provided via email and a read receipt confirms receipt of the report. AD has agreed to sign the report and return a signed copy to LPA.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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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