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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411357
Report Date: 01/31/2022
Date Signed: 01/31/2022 03:47:10 PM

Document Has Been Signed on 01/31/2022 03:47 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SLB INC CALLE PRIMAFACILITY NUMBER:
336411357
ADMINISTRATOR:COTADELA BALATBATFACILITY TYPE:
735
ADDRESS:21650 CALLE PRIMATELEPHONE:
(951) 776-0424
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 5DATE:
01/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Cotadela BalatbatTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA), David Cuevas, conducted an unannounced visit to the facility to conduct a case management follow up visit to address an incident involving the death of Client One (C1). LPA met with Administrator, Cotadela Balatbat who was informed of the purpose of visit and allowed entry.

During visit LPA made request for C1’s IPP and Physicians report. No citations have been issued at this time.

An exit interview was conducted with Administrator, Cotadela Balatbat were a copy of this report and LIC 811 was reviewed with and provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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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