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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530063
Report Date: 02/27/2023
Date Signed: 02/27/2023 10:51:53 AM

Document Has Been Signed on 02/27/2023 10:51 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SIERRA PINES GUEST HOMEFACILITY NUMBER:
335530063
ADMINISTRATOR:HAMED, HANANFACILITY TYPE:
740
ADDRESS:5051 LA SIERRA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 25CENSUS: 24DATE:
02/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Hanan Hamed, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Sierra Pines Guest Home for a follow up visit for Pre-Licensing Visit. LPA introduced self and stated the purpose of the visit. LPA was greeted and invited inside by Administrator. LPA signed in and completed a walk through the facility with Administrator. The current census is 24, there are no staff members or resident showing symptoms or have contracted COVID19. Ibraheem Hamed, Administrator arrived later during the visit.

Administrator took LPA to Resident Room #5. LPA observed the areas along the wall and behind the room door where the dry wall had been fixed and painted. LPA and Administrator walked the yard area behind the facility. LPA observed the walkways had been clear and orderly. Free of obstruction from the bushes that were obstructing the path prior.

After walk through, Administrator provided LPA with resident and staff files. LPA completed a records review of each file. LPA observed each file to be organized and included the required documentation as regulated.
Comp. III completed.

The facility was evaluated in accordance with the CCR, Title 22 California Code of Regulations. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure. An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided with Administrators Ibraheem Hamed and Hanan Hamed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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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