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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881335
Report Date: 08/19/2022
Date Signed: 08/19/2022 10:32:38 AM


Document Has Been Signed on 08/19/2022 10:32 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 0DATE:
08/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Melayna Lagasca, LicenseeTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced and met with Licensee Melayna Lagasca. The facility is now closed and the last resident moved out from the facility on August 1, 2022.
During today's visit, LPA verified there were no residents in care. Per Lagasca, Resident #1 (R1) moved out on August 1, 2022 and moved in with family located in Lancaster. LPA obtained the contact information for R1 as well. Lagasca surrendered the facility's license to LPA during the visit.

An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names List.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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