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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881308
Report Date: 08/22/2023
Date Signed: 08/22/2023 10:26:10 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/22/2023 10:26 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A PLACE OF LOVEFACILITY NUMBER:
331881308
ADMINISTRATOR:MOJICA, FLORENCEFACILITY TYPE:
735
ADDRESS:1360 N PALM AVETELEPHONE:
(951) 665-3192
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 6CENSUS: 0DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Licensee Florence MojicaTIME COMPLETED:
10:30 AM
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On 8/22/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct a required annual inspection. LPA did not receive an answer at the door and contacted Licensee Florence Mojica over the phone to inform them of the purpose of LPA's visit. Licensee Mojica met LPA at the facility and granted LPA entry.

LPA was informed that the home is vacant as the facility is pending approval from the Assisted Living Waiver program. LPA toured the facility's interior and exterior and did not observe any clients in care, or evidence to suggest the home is currently occupied.

The facility is approved to care for six (6) non-ambulatory clients and serves adults ages 18 through 59. The facility is made up of four (4) client bedrooms, two (2) client bathrooms, a kitchen, living and dining room.

During today's visit, LPA did not observe any issues or concerns. Licensee Mojica will inform Community Care Licensing's Riverside Regional Office when the facility gets client placement.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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