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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411357
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:03:23 PM

Document Has Been Signed on 01/22/2025 04:03 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:SLB INC CALLE PRIMAFACILITY NUMBER:
336411357
ADMINISTRATOR/
DIRECTOR:
COTADELA BALATBATFACILITY TYPE:
735
ADDRESS:21650 CALLE PRIMATELEPHONE:
(951) 776-0424
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 6DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Cotadela Balatbat-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Debbie Palacios conducted an unannounced one (1) year required visit. LPA was granted entry by Administrator Cotadela Balatbat , who was informed of the purpose of visit. At the time of the visit there were three (3) staff, Administrator and six (6) clients present. All staff present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA observed the following during today's visit:

LPA conducted a tour of the facility with Administrator, Cotadela. The physical plant is a single story structure that contained four (4) client bedrooms, one (1) staff bedroom, and three (3) bathrooms. The facility has a (1) dining room, kitchen, living room, garage, Laundry room and a gated backyard. Indoor and outdoor passageways were free of obstruction. Facility has a locked gated swimming pool with safety devices. The facility has more than a two (2) day supply of perishable food and seven (7) day supply of non-perishable foods. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items were observed in a locked cabinet in the kitchen. Client bedrooms had the required bedding, furniture, and lighting. The smoke and carbon monoxide detectors were tested and were observed to be operable. Centrally stored medication was observed in a locked cabinet in the kitchen. One (1) fully charged fire extinguisher was observed to be mounted in the kitchen wall. The living room was observed to have board games and other activities. The facility was observed to be in a clean condition; free of dirt, insects, rodents, and pests.

Staff files reviewed include but not limited to have personnel records, health screenings, criminal record clearance, required training, and valid first aid/CPR certification. Client files included but are not limited to signed admission agreements, pre-placement, personal rights, house rules, needs and service plans, and updated physician reports. Facility sketch, CCL complaint poster are posted on a wall in the living room.


During today's visit, LPA did not observe any immediate violations or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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