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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881436
Report Date: 08/22/2023
Date Signed: 08/22/2023 01:25:38 PM


Document Has Been Signed on 08/22/2023 01:25 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:DOLORES HOMECARE IIFACILITY NUMBER:
331881436
ADMINISTRATOR:CAYABYAN, ANSONFACILITY TYPE:
740
ADDRESS:68280 MARINA ROADTELEPHONE:
(760) 218-8906
CITY:CATHERDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 7DATE:
08/22/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator, Anson CayabyabTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with the Administrator, Anson Cayabyab. LPA was informed that seven (7) residents currently reside at this facility, with a capacity of six (6). There were nine (9) staff on duty during the time of the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care. Due to the state of emergency of having to relocate all residents from Affinity Senior II, LPA observed seven (7) residents at the facility. The capacity is six (6), the Administrator stated that he will be moving R1 to Affinity Senior Living by August 23, 2023. The Administrator states that they have sufficient PPE, first aid requirements, gloves.

No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Administrator, Anson Cayabyab and a copy of this report is left with him as evidence by his signature.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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