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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881496
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:26:50 PM

Document Has Been Signed on 06/21/2024 04:26 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SHORELINE ST HOME LLCFACILITY NUMBER:
331881496
ADMINISTRATOR/
DIRECTOR:
DATO, MARIEROSEFACILITY TYPE:
735
ADDRESS:25830 SHORELINE STREETTELEPHONE:
(951) 485-3490
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 4CENSUS: 4DATE:
06/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:26 PM
MET WITH:Applicant, Roy MartinTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Janira Arreola, made an announced visit to the facility in order to conduct a pre licensing inspection. LPA met with Applicant, Roy Martin, and administrator Mae Boco who were informed of the purpose of the visit. During the visit there were (1) clients and (3) staff present.

The facility is seeking a change in ownership. The facility will be licensed as an adult residential facility, with capacity of (4) non-ambulatory clients approved by the local fire department. The facility does not have a pool or firearms. The home is a one story home with (4) bedrooms and (2) bathrooms. (1) bedroom is for staff. The home currently has clients in care. LPA conducted a walk through of the interior and exterior of the facility. The bedrooms have all the required furniture, and required hygiene supplies, and linens. LPA observed the hallway lights and the carbon monoxide detectors were in good working condition. The outdoor area was free of any hazards and had a shaded area for residents and an emergency exit. The kitchen had the ability to prepared food is a clean and safe environment. LPA observed the food supply met the department requirements. LPA observed locked areas designated for medication, sharp objects, and cleaning supplies. The hot water temp was measures at 105.8F. The facility has a land line at (951) 485-8065. Common spaces are available for clients to engage in activities. The staff present during the visit have criminal record clearance and CPR training. LPA observed areas were the staff and resident files are kept LPA reviewed a staff schedule showing adequate staff coverage. The Administrator has a current administrator’s certificate. Each resident has a separate file that is kept at the facility.

No health or safety hazards were observed during the time of the visit. There are no objections for the applicant to proceed in the pre licensing process. An exit interview was conducted with the applicant, and copy of this report was reviewed and provided to them.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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