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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881331
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:14:07 PM

Document Has Been Signed on 06/20/2024 04:14 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/
DIRECTOR:		JOHNSON, LA SUNEAFACILITY TYPE:
735
ADDRESS:3656 GINGER STTELEPHONE:
(818) 818-1817
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:42 PM
MET WITH:Erica Graham-Bullock, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 6/20/2024, Licensing Program Manager (LPM) Tricia Danielson and Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct a case management visit at the facility and met with Licensee (LIC), Erica Graham-Bullock.

LPM and LPA conducted a tour of the facility to verify the census. Licensee reported there are six (6) residents currently residing in the home. LPM and LPA observed three (3) residents leaving upon their arrival to the home. LPM and LPA observed a total of an additional six (6) residents in the home during today's visit. Per LIC, those three (3) residents were visiting their friends who reside here at the facility. Per LIC, friends of the residents visit occasionally. LPA inquired with LIC regarding an incident concerning law enforcement which occurred near the facility yesterday, June 19, 2024. Per LIC, she is not aware of how many residents were present at the facility at the time of the incident.

No deficiencies cited during today's visit. An exit interview was conducted and a copy of this report was provided to LIC.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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