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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402597
Report Date: 01/07/2025
Date Signed: 01/07/2025 11:17:08 AM

Document Has Been Signed on 01/07/2025 11:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SLB INCORPORATED-OLD VALLEYFACILITY NUMBER:
336402597
ADMINISTRATOR/
DIRECTOR:		FORTAJADA, JAMIELAHFACILITY TYPE:
735
ADDRESS:23484 OLD VALLEY DRIVETELEPHONE:
(951) 243-9746
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 5DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Administrator, Cotadela BalatbatTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Annual Required Visit. LPA was granted entry by and met with Administrator, Cotadela Balatbat, and CEO of SLB INC. Michael Hall, who were informed of the purpose of the visit. During the time of the visit there were (5) clients and (5) staff.

The facility is a (1) story home with (4) bedrooms and (2) bathrooms for clients. There are no bodies of water, weapons or fire arms kept at the facility. LPA conducted interviews, records review and a walk through.

LPA observed the kitchen had equipment in good working condition. The facility meets the (2) day perishable and (7) day non-perishable supply of food. The knifes and cleaning supplies were kept locked.

The outdoor area was observed to be free of hazards and has an emergency exit. LPA observed the resident bedrooms had the required furniture and the bathrooms have grab bars and hygiene supplies for residents. The hot water temperature was recorded at 105F and the carbon monoxide and smoke alarms are in working condition. There are cleaning supplies to do regular cleaning of the facility. Required postings are found in the entry way, and emergency and PPE supplies were kept in a staff room.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SLB INCORPORATED-OLD VALLEY
FACILITY NUMBER: 336402597
VISIT DATE: 01/07/2025
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LPA reviewed (5) resident records which possessed all required paper work. LPA reviewed (5) staff records which possessed all required records and training. The current administrator meets the Administrator requirements and has a current Administrator's Certificate. The staff schedule showed staff coverage at all times.

The resident medication was kept locked in a cabinet. LPA reviewed resident medications which were accounted for on the centrally stored medication lists and Medication Administration Records (MAR).

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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