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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402597
Report Date: 04/26/2023
Date Signed: 04/26/2023 03:44:25 PM

Document Has Been Signed on 04/26/2023 03:44 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:
04/26/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Michael Hall, CEOTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Jesse Gardner met with CEO Michael Hall at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 04/26/2023 at 03:00 PM to deliver an amended version of a report dated September 7, 2022.

LPA met with CEO Michael Hall to issue amended report dated September 7, 2022. Administrator Jamielah Fortajadah arrived in the office during the meeting.

An exit interview was conducted where this report was discussed and a copy of the report was provided along with the amended report.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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