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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408867
Report Date: 10/10/2022
Date Signed: 10/10/2022 10:16:53 AM

Document Has Been Signed on 10/10/2022 10:16 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOMESTEAD HAVENFACILITY NUMBER:
336408867
ADMINISTRATOR:VICTOR UGARTEFACILITY TYPE:
735
ADDRESS:14307 HOMESTEAD DRIVETELEPHONE:
(951) 707-3906
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: DATE:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Victor Ugarte, AdministratorTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Jesse Gardner made an announced visit to the facility for the purpose of conducting a required annual inspection. An appointment was made to meet with the Administrator for this visit as a previous attempt to complete the inspection was unsuccessful on 09/07/2022. LPA met with Administrator Victor Ugate. There are currently no clients in care. The facility is currently under renovation, due to recent water damage. Victor Ugate has chosen to maintain the license for the facility and plans on placing clients in the home once renovations are complete.

During LPA's inspection, LPA noted drywall removed, exposed framing, no sinks, or food in the kitchen, no stove, and no furniture for client use. The facility is uninhabitable.

LPA issued (2) Technical Violations for the condition of the facility, as well as the debris inside and outside the facility. An exit interview was conducted where a copy of this report, and both LIC9102's were discussed and provided to the Administrator.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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