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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881308
Report Date: 08/16/2024
Date Signed: 08/16/2024 01:34:00 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/16/2024 01:34 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:A PLACE OF LOVEFACILITY NUMBER:
331881308
ADMINISTRATOR/
DIRECTOR:		MOJICA, FLORENCEFACILITY TYPE:
735
ADDRESS:1360 N PALM AVETELEPHONE:
(951) 665-3192
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 6CENSUS: 0DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Florence Mojica, licenseeTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Seo Jeon 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 her of the purpose of LPA's visit. The licensee met LPA at the facility at 1:08 pm and toured the facility.

The facility is a single story home with four (4) bedrooms and two (2) bathrooms with attached garage. There are no pools or other bodies of water located on the premises and no firearms or other dangerous weapons are stored at the facility. The clients served are adults between the ages of 18-59.

LPA was informed that the home is vacant as the facility is pending approval for change of facility type. 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.



During today's visit, LPA did not observe any issues or concerns.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was provided to Licensee, Florence Mojica.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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