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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402597
Report Date: 04/27/2022
Date Signed: 04/27/2022 12:18:09 PM

Document Has Been Signed on 04/27/2022 12:18 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:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Dennis Pontawe, CaregiverTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection with an emphasis on infection control.

LPA met with Caretaker Dennis Pontawe and toured the facility. Present in the facility during time of visit were 5 residents. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings were observed.

During the visit, CEO/Administrator Michael Hall arrived inside the facility.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. LPA later discussed infection control practices and procedures with Mr. Hall.

There were no deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was discussed with and provided to Mr. Hall.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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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