<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881317
Report Date: 09/11/2023
Date Signed: 09/11/2023 01:39:00 PM

Document Has Been Signed on 09/11/2023 01:39 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MISSION BELL ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
331881317
ADMINISTRATOR:BOYER, MARITESFACILITY TYPE:
735
ADDRESS:435 IDYLLWILD DRIVETELEPHONE:
(951) 654-0774
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 15CENSUS: 13DATE:
09/11/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Alicia Mercado, CaregiverTIME COMPLETED:
01:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Yolanda Delgado arrived to the facility unannounced to conduct a Case Management visit on the Health and Safety check. There were two (2) staff on duty and four (4) residents, other residents are at Program. There were no concerns of Health and safety for residents in care. There are working utilities and sufficient food.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1