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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881331
Report Date: 06/29/2023
Date Signed: 06/29/2023 01:06:52 PM

Document Has Been Signed on 06/29/2023 01:06 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:ERICA B INDEPENDENT LIVING FACILITYFACILITY NUMBER:
331881331
ADMINISTRATOR:JOHNSON, LA SUNEAFACILITY TYPE:
735
ADDRESS:3656 GINGER STTELEPHONE:
(818) 818-1817
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 5DATE:
06/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Erica Graham-Bullock, LicenseeTIME COMPLETED:
01:09 PM
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Licensing Program Analyst's (LPA) Jesse Gardner and Venus Mixson arrived to the facility to continue a possible unlicensed operation (18-AS-20230622154454) investigation that the Department was conducting that was related to this facility.

During the visit, LPAs interviewed Resident One (R1), and Resident Two (R2) who were inside the facility upon LPAs arrival. No deficiencies were noted at the conclusion of the visit.

An exit interview was conducted with Licensee Erica Graham-Bullock and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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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