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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881543
Report Date: 08/15/2024
Date Signed: 08/15/2024 03:00:30 PM

Document Has Been Signed on 08/15/2024 03:00 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:UNITED IN CHANGE - AVENIDA HOUSEFACILITY NUMBER:
331881543
ADMINISTRATOR/
DIRECTOR:		MONTGOMERY, MONICAFACILITY TYPE:
735
ADDRESS:26452 AVENIDA DE LA PAZTELEPHONE:
(951) 498-1770
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 0DATE:
08/15/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Etta Simpson, ApplicantTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs), Stephanie Martinez and Armando Perez, conducted an announced pre-licensing inspection at the home to follow up on corrections identified during the initial pre-licensing visit on 07/29/2024. The LPAs met with Applicant, Etta Simpson.

The LPAs toured the facility. The LPAs observed the backyard to be cleaned up and sufficiently maintained. The LPAs observed all client bedrooms to be cleared out of personal items and ready for new client admissions. The drawer and closet door to be functioning properly. LPAs observed the hall bathroom to be cleaned up. No additional follow up is required at this time.

The Centralized Applications Unit will be contacted and notified the home is ready to move forward in the licensing process.

This report was reviewed with Applicant Simpson and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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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