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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402597
Report Date: 07/20/2022
Date Signed: 07/20/2022 02:04:52 PM

Document Has Been Signed on 07/20/2022 02:04 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: 6DATE:
07/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Dennis Pontawe, CaretakerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to follow up on information reported to the Department in relation to R1 and S1.

LPA met with Caretaker Dennis Pontawe and toured the facility. Present in the facility during time of visit were 6 residents. At the time of visit, LPA interviewed R1, R2, R3, R4, R5, and R6. LPA also interviewed S2, S3, S4, S5 and S6. LPA reviewed R1's file and obtained copies of pertinent documents.

An exit interview was conducted and a copy of this report was reviewed with and provided to Administrator Hall along with copies of the LIC811, and LIC811-C.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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