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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403457
Report Date: 12/07/2021
Date Signed: 12/07/2021 03:32:58 PM

Document Has Been Signed on 12/07/2021 03:32 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:BRILLO ADULT RESIDENTIAL CARE #2FACILITY NUMBER:
336403457
ADMINISTRATOR:INGRID E. BRILLOFACILITY TYPE:
735
ADDRESS:13830 MANGOWOOD DR.TELEPHONE:
(951) 243-9727
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 3DATE:
12/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Jeremy HilarioTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to deliver amended complaint (18-AS-20201014100304) report originally received at Licensing office on 10/14/2020 with findings delivered, via electronic format, on 10/16/2020. LPA Prieto met Jeremy Hilario, report was signed by both LPA Prieto and Jeremy Hilario and signed copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
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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