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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881465
Report Date: 12/19/2024
Date Signed: 12/19/2024 10:42:42 AM

Document Has Been Signed on 12/19/2024 10:42 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BUILDING HOPE COMMUNITY SERVICES LLCFACILITY NUMBER:
331881465
ADMINISTRATOR/
DIRECTOR:		JITE, DAVIDFACILITY TYPE:
735
ADDRESS:1737 DOBELL STREETTELEPHONE:
(562) 308-0847
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 2DATE:
12/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee, David JiteTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Plan of Correction Visit to the facility. LPA met with Staff Ariana Wilson, who was informed of the purpose of the visit. Licensee, David Jite later arrived to meet LPA. LPA conducted a walk through, interviews, observations and record review.

The following deficiency was cleared during the time of the visit:


On 12/9/2024, LPA conducted a Case Management Deficiencies visit where, California Code of Regulations Title 22 Section 80065(a) Personnel Requirements was cited for no staff being present at the time the LPA arrived to the facility. The plan of correction was to send the LPA a copy of an updated LIC500 showing staff coverage at all times by 12/10/2024. LPA received a copy of the LIC500 on 12/10/2024 which did not have staff names or schedules, LPA sent back the LIC500 for corrections with filled in dates, times, and staff names covering shifts and granted an extension to 12/11/2024.

On 12/11/2024 LPA received a revised copy of the LIC500 showing (1) staff covering shifts Wednesday, Thursday, and Friday from 8am to 2pm with no other staff shifts documented. LPA requested the LIC500 be revised showing coverage at all times, where Licensee stated the would provide the updated LIC500. On 12/13/2024 LPA received a revised version of the LIC500, upon review of the form and licensee interview the LIC500 shows staff coverage at all times.



LPA arrived to the facility for the visit 12/19/2024 and observed staff present for the supervision of the residents. Therefore the plan of correction has been met and the deficiency was cleared at the time of the visit. An exit interview was conducted where this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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