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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403188
Report Date: 12/16/2022
Date Signed: 12/16/2022 12:14:18 PM


Document Has Been Signed on 12/16/2022 12:14 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SHEPHERD WATCH ELDERLY CARE HOMEFACILITY NUMBER:
336403188
ADMINISTRATOR:DAVIS, BARBARAFACILITY TYPE:
740
ADDRESS:3180 W. GEORGE ST.TELEPHONE:
(951) 849-6289
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:4CENSUS: 0DATE:
12/16/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Barbara DavisTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Paola Guerrero conducted an announced visit to conduct a final walk-through purpose of facility closure. LPA arrived and met with Barbara Davis, LPA, Guerrero conducted a walk through of the facility both inside and outside. LPA, Guerrero verified that there were no residents present, and there were no belongings of residents in the facility. LPA Guerrero was informed all residents have been relocated and facility has been closed since 07/21. LPA inspected the entire facility which included the bedrooms, bathrooms, dining area, kitchen, and the backyard. Home is currently being used as a private residence. Administrator stated reason for closure is due to retirement.


LPA, Guerrero requested license from the licensee, Barbara provided license to LPA.

The effective date of closure will be 12/16/2022.

An exit interview was conducted, and a copy of this report was discussed and provided to Administrator Barbara Davis.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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