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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410667
Report Date: 11/20/2023
Date Signed: 11/20/2023 01:29:28 PM


Document Has Been Signed on 11/20/2023 01:29 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: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:
11/20/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Nilda Agtang, CaregiverTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to the facility to conduct a case management visit to check on the health, safety, and welfare of residents in care.

LPA met with Caregiver, Nilda Agtang who allowed LPA entry. LPA was informed that four (4) residents currently reside at this facility. 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. The food supply meets the 7-day non-perishables, and 2-day perishables regulatory requirement. There are no immediate concerns 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 where a copy of this report was discussed with and provided to Caregiver, Nilda Agtang.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
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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