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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530098
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:39:19 PM

Document Has Been Signed on 10/10/2023 03:39 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:COBBLE CREEK HOMEFACILITY NUMBER:
335530098
ADMINISTRATOR:SANASINH, SIMM K.FACILITY TYPE:
740
ADDRESS:7462 COBBLE CREEK DRTELEPHONE:
(951) 427-1058
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 0DATE:
10/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Simm Sanasinh, Administrator
Brook Sanasinh, Licensee		TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 07/07/2023 for a total capacity of Four (4) ambulatory and two (2) non-ambulatory residents. Fire Clearance was granted 07/17/2023 LPA Goldenberg observed the following:

Structure: Facility was a single story house with four (4) resident bedrooms, three (3) bathrooms, living room, dining area, den and kitchen area.
Heating/Cooling System: Central heating and air conditioning systems.
Bedrooms: Each resident bedroom will accommodate. All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.
Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by applicant and thermometer read by LPA at 106F.
Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.
Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.
Linens and Hygiene Supplies: An adequate supply of linens was available.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: COBBLE CREEK HOME
FACILITY NUMBER: 335530098
VISIT DATE: 10/10/2023
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Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.
Garage: Laundry area with washer and dryer were located behind a locked door. Laundry detergents and cleaning solutions were secured behind a locked cabinet door. Garage was organized and free of obstructions.
Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and clients rights are posted.
General items: The facility has smoke detectors and carbon monoxide. These were tested and operational. LPA observed a facility phone and it was verified to be operational by LPA.

LPA reviewed COMPONENT III with the applicant during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time. This report was reviewed with and a copy provided to the applicant.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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