<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412332
Report Date: 04/27/2023
Date Signed: 04/27/2023 10:53:31 AM

Document Has Been Signed on 04/27/2023 10:53 AM - 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:NATHANS ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
336412332
ADMINISTRATOR:JED AQUINOFACILITY TYPE:
735
ADDRESS:10980 KAYJAY ST.TELEPHONE:
(951) 353-2199
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 4DATE:
04/27/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Myrna Evangelista, CaregiverTIME COMPLETED:
10:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Yolanda Delgado 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 Myrna Evangelista, Caregiver. LPA was informed that four (4) residents currently reside at this facility; two (2) residents at Day Program. There were one (1) staff on duty during the time of the visit.

LPA observed all facility utilities to be on and operating without issue. There is an adequate food supply and all residents have prescribed meds.

Based on the information obtained during today's visit, there are no deficiency that are being cited per California Health & Safety Code and Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Myrna Evangelista and a copy of this report will be emailed to the facility and a confirmation receipt will be requested.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1