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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881495
Report Date: 05/03/2024
Date Signed: 06/05/2024 03:44:45 PM

Document Has Been Signed on 06/05/2024 03:44 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:SHADOWBROOK ST HOME LLCFACILITY NUMBER:
331881495
ADMINISTRATOR/
DIRECTOR:		MARTIN, ROY L. IIFACILITY TYPE:
735
ADDRESS:12640 SHADOWBROOK STREETTELEPHONE:
(951) 377-3763
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: DATE:
05/03/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Component II completion: Successful

Facility Type: ARF
Application Type: CHOW
Capacity: 6, 6, 4, 4
Census (if any clients in care): clients in care
COMP II Participants: Roy Marin II, Owner/administrator
Interview Method: Telephone interview

On May 5, 2024, applicant(s)/administrator participated in COMP II for the below pending facilities: La Palma Way Home LLC, 331881500; White Box Lane Home, LLC, 331881502; Jumano Dr Home LLC, 331881499; Shadowbrook St Home LLC, 331881495. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Shannon Betker
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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