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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881180
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:20:04 PM

Document Has Been Signed on 11/20/2023 02:20 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:
11/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Comfort Olaniyan, DSPTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Javina George arrived unannounced to the facility, to deliver findings for complaint #18-AS-20201112171550.

The complaint is not associated with this facility, as the facility had a name change. The Administrator is currently out of the Country, and was unable to via telephone or to come to the facility. LPA met with DIrect Support Professional (DSP) Comfort Olaniyan and explained the purpose of the visit.

An exit interview was conducted and a copy of this report was provided to DSP Comfort Olaniyan.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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