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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881116
Report Date: 03/25/2024
Date Signed: 03/25/2024 02:22:15 PM


Document Has Been Signed on 03/25/2024 02:22 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:ELIAA, LLCFACILITY NUMBER:
331881116
ADMINISTRATOR:YOUNES, AMIRRAFACILITY TYPE:
740
ADDRESS:11545 DOVERWOOD DR.,TELEPHONE:
(650) 656-7941
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:6CENSUS: 6DATE:
03/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:House Manager/Licensee Ahmed QasimTIME COMPLETED:
02:30 PM
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On 03/25/2024 at 01:30 PM, Licensing Program Analyst (LPA) Melody Brown made an announced visit to the facility to amend the forms LIC809C, LIC809D and LIC421BG issued on 03/21/2024 due to incorrect amount on Civil Penalty Assessment Issued. LPA Brown met with House Manager/Licensee Ahmed Qasim and was granted entry to the facility. At the time of the visit there's two (2) staff present, and six (6) residents present.

During this visit, LPA Brown amended the forms LIC809C, LIC809D, LIC421BG issued on 03/21/2024 due to incorrect amount on Civil Penalty Assessment Issued for two (2) individuals living at the adjacent two-storey building located at the back of the facility compound without criminal background clearance since 01/05/2024 which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty of $500.00/per individual will be assessed today, 03/25/2024.

An exit interview was conducted, and this report (LIC809), and amended copies of LIC809C, LIC809D, LIC421BG and Appeal Rights were discussed and provided to House Manager/Licensee Ahmed Qasim.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024
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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