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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881180
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:21:47 PM

Document Has Been Signed on 10/26/2023 04:21 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALICE CARE RESIDENTIAL HOME INC.FACILITY NUMBER:
331881180
ADMINISTRATOR:ALOFE, OLUWAKEMI TFACILITY TYPE:
735
ADDRESS:23888 LONE PINE DRIVETELEPHONE:
(951) 208-0344
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 3DATE:
10/26/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Oluwakemi Alofe, AdministratorTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Javina George arrived to the facility to conduct an unannounced collateral visit regarding a complaint #18-AS-20201112171550, that occurred at another facility.

During today's visit, LPA interviewed one staff and reviewed staff files.

An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list was provided to Oluwakemi Alofe, Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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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