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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336405670
Report Date: 09/10/2021
Date Signed: 09/10/2021 03:33:53 PM

Document Has Been Signed on 09/10/2021 03:33 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-MESA TOPFACILITY NUMBER:
336405670
ADMINISTRATOR:LIBERTY HALLFACILITY TYPE:
735
ADDRESS:28331 MESA TOP TRAILTELEPHONE:
(951) 485-6779
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 4DATE:
09/10/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Michael Hall - AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Crystal Colvin met with Administrator Michael Hall off-site for the purpose of obtaining signatures to an amended complaint report (#18-AS-20200115104818) in which a technical error was made. LPA Colvin went over the amended report with Administrator Michael Hall and provided copies of both the amended complaint report as well as this report memorializing the signing of the amended report.

An exit interview was conducted and a copy of all reports was provided to Administrator Michael Hall.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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