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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881335
Report Date: 05/18/2022
Date Signed: 05/18/2022 11:21:34 AM


Document Has Been Signed on 05/18/2022 11:21 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:FOR HIS GRACE SENIOR CARE HOMEFACILITY NUMBER:
331881335
ADMINISTRATOR:NAVARRA, TERESAFACILITY TYPE:
740
ADDRESS:12537 POINSETTA DRTELEPHONE:
(951) 689-0182
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: DATE:
05/18/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Teresa Navarra & Melayna LagascaTIME COMPLETED:
10:40 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 2
Method: Telephone call with CAB
COMP II Participants: Teresa Navarra & Melayna Lagasca

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant/administrator has been advised to transmit signed LIC 809 with copy of photo ID to CAB.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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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