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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403275
Report Date: 03/24/2021
Date Signed: 03/24/2021 03:29:27 PM

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:PUTTERS LANE ASSISTED LIVINGFACILITY NUMBER:
336403275
ADMINISTRATOR:COCCHIARO, KAREN EILEENFACILITY TYPE:
740
ADDRESS:43307 PUTTERS LANETELEPHONE:
(951) 927-8651
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 4DATE:
03/24/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Juanita DuranTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to conduct a health and safety check. LPA met with Caregiver, Juanita Duran, and discussed the purpose of the visit.

LPA toured the facility and inspected resident rooms, bathrooms, and common areas. LPA inspected the facility food supplies and observed an adequate supply of perishable and non-perishable food. Medications, sharps, and cleaning supplies were locked and inaccessible to residents. LPA also observed that utilities such as the electricity, gas, and water were functioning. During the inspection, LPA observed residents watching TV and sleeping. LPA determined that residents in care appeared to be safe with no imminent health or safety concerns.

An exit interview was conducted where this report (LIC 809) was discussed and provided to the administrator via email.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
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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