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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881158
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:15:51 PM

Document Has Been Signed on 07/20/2022 03:15 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:OLIVER ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
331881158
ADMINISTRATOR:ADELEYE, JOHNPAULFACILITY TYPE:
735
ADDRESS:13675 OLIVER STREETTELEPHONE:
(951) 289-2731
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 0DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Chibunna Nwaobia, House ManagerTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA), Stephanie Torres, made an announced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA met with House Manager, Chibunna Nwaobia, and informed him of the purpose of the visit. There are currently no clients in care.

The LPA toured the facility and observed no clients in care. Per Nwaobia, the home is pending vendorization through Inland Regional Center (IRC).

The LPA advised Nwaobia to ensure the Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report is reviewed and COVID-19 guidelines are put into place prior to the admission of any clients into the home. The LPA advised the manager to contact the Regional Office when one or more clients are admitted in order for the Department to conduct a follow up visit to the home to ensure compliance with state regulation and COVID-19 guidance. Nwaobia verbalized his understanding.

This report was reviewed with Nwaobia and a copy was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
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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