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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530098
Report Date: 11/01/2024
Date Signed: 11/01/2024 02:49:40 PM

Document Has Been Signed on 11/01/2024 02:49 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COBBLE CREEK HOMEFACILITY NUMBER:
335530098
ADMINISTRATOR/
DIRECTOR:		SANASINH, SIMM K.FACILITY TYPE:
740
ADDRESS:7462 COBBLE CREEK DRTELEPHONE:
(951) 427-1058
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 5DATE:
11/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator -Simm K. Sanashinh and Caregiver - Maria Victoria CorcueraTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Mary Rico conducted an announced visit to the facility for the purpose of a change of ambulatory, non-ambulatory and bedridden. LPA was greeted and granted entrance by caregiver Maria Victoria Corcuera.

Per the LIC200, Licensee requested for the change of ambulatory, non-ambulatory and bedridden. The facility went from (0) bedridden to (1) bedridden. For ambulatory from (6) to (4) ambulatory residents. In addition, for non-ambulatory from (0) to (1). The fire clearance request was approved on 10/22/2024 for (1) non-ambulatory, (4) ambulatory clients and (1) bedridden.

The licensee was advised that the noted designated capacity and status for each room is to remain in compliance.

LPA observed that the residents’ bedrooms were appropriately furnished and had functional lighting. The physical plant is ready. LPA will update the facility's file and issue a new license.

An exit interview was conducted where this report LIC809 was discussed and provided to caregiver Maria Victoria Corcuera and Administrator Simm K. Sanashinh.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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