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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408867
Report Date: 11/20/2024
Date Signed: 11/20/2024 12:38:54 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/20/2024 12:38 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOMESTEAD HAVENFACILITY NUMBER:
336408867
ADMINISTRATOR/
DIRECTOR:		VICTOR UGARTEFACILITY TYPE:
735
ADDRESS:14307 HOMESTEAD DRIVETELEPHONE:
(951) 707-3906
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 0DATE:
11/20/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Licensee and Administrator, Victor UgarteTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Anaylst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a walk through and continue the annual inspection initiated on 9/19/2024. LPA met with and was granted entry by Licensee and Administrator, Victor Ugarte who was informed of the purpose of the visit. At the time of the visit there is no staff or clients present.

The visit is in response to telephone conversation with the licensee where it was revealed that the facility is undergoing repairs. LPA conducted a tour of the home on today's date and observed the home requires, plumbing, furniture, care supplies, and cleaning of debris. The home is not suitable for clients at this time. The licensee acknowledged that clients will not be admitted until further repairs are completed. The licensee agreed to contact the department with progress of the repairs, and when repairs are completed.

An exit interview was conducted with the licensee where this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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