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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881187
Report Date: 10/04/2021
Date Signed: 10/04/2021 11:44:27 AM

Document Has Been Signed on 10/04/2021 11:44 AM - 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:SHAFFER SENIOR CARE, LLCFACILITY NUMBER:
331881187
ADMINISTRATOR:SHALABI, JAMALFACILITY TYPE:
740
ADDRESS:672 SHAFFER STREETTELEPHONE:
(337) 244-2252
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 6CENSUS: 0DATE:
10/04/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jamal ShalabiTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility to conduct a prelicensing visit. Upon arrival, LPA Brown met with Administrator Jamal Shalabi. On 07/13/21, the home was approved by the Corona Fire Department for a capacity of six (6) ambulatory residents. There is no approval for delayed egress or locked perimeters and nonambulatory residents. A tour of the physical plant was conducted inside and out with Administrator Shalabi. The home has three (3) bedrooms. Room #1 will have two (2) residents, Room #2 will have two (2) residents, Room #3 will have two (2) residents. Each room is equipped with appropriate furnishings. There were plenty of linens and hygiene supplies present. Perishable and nonperishable foods will be purchased when licensed. Water temperature measured at 105 degrees F. Smoke detectors and a carbon monoxide detector were present and in working order. There was also a charged fire extinguisher present. All toxins will be locked, and medications will be stored inaccessible to residents. All resident and staff files will be locked for privacy. Facility has a shaded area outside with patio furniture. Emergency supplies of water and food will also be provided once licensed.

The facility was evaluated in accordance with Title 22, Division 6, Chapters 1 to ensure the health and safety of residents in care and meets regulation guidelines at this time.

No corrections are needed.

Administrator Shalabi will be notified of the final licensing date by phone upon final management review and approval, and then the license will be mailed.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2021
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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