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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402597
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:06:49 PM

Document Has Been Signed on 03/10/2022 02:06 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
RIVERSIDE, CA 92507
FACILITY NAME:SLB INCORPORATED-OLD VALLEYFACILITY NUMBER:
336402597
ADMINISTRATOR:FORTAJADA, JAMIELAHFACILITY TYPE:
735
ADDRESS:23484 OLD VALLEY DRIVETELEPHONE:
(951) 243-9746
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 5DATE:
03/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jamielah Fortajada, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Tricia Danielson, Javina George, Janira Arreloa arrived unannounced to the facility conduct a case management visit following receipt of a death report of Client #1 (C1)

LPAs reviewed file of C1 and made photographic copies of pertinent documents. LPAs also interviewed facility Administrator Jamielah Fortajada. Fortajada reported she was notified of C1's death by their mother that C1 passed away on 3/8/2022 at Riverside University Health System hospital.

There were no deficiencies cited during today's visit. An exit interview was conducted and a copy of this report was provided along with LIC 811- Confidential Names list.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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