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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410667
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:47:48 PM


Document Has Been Signed on 10/10/2023 01:47 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:DOLORES HOMECAREFACILITY NUMBER:
336410667
ADMINISTRATOR:ANALISA CAYABYABFACILITY TYPE:
740
ADDRESS:30758 BLOOMSBURY LANETELEPHONE:
(760) 202-6609
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:4CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Caregiver, Nilda AgtangTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with the Caregiver, Nilda Agtang. LPA was informed that four (4) residents currently reside at this facility, with a capacity of four (4). There were two (2) staff on duty during the time of the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care.

No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Caregiver, Nilda Agtang and a copy of this report is left with the her as evidence by her signature.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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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