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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413086
Report Date: 11/15/2024
Date Signed: 11/15/2024 08:20:21 AM

Document Has Been Signed on 11/15/2024 08:20 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
, CA 92507
FACILITY NAME:MC BOARD & CAREFACILITY NUMBER:
336413086
ADMINISTRATOR/
DIRECTOR:		MARIA AGUILARFACILITY TYPE:
740
ADDRESS:24259 BRILLANTE DRIVETELEPHONE:
(951) 813-2143
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Licensee/Administrator Maria AguilarTIME VISIT/
INSPECTION COMPLETED:
08:30 AM
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On 11/15/2024 at 08:00 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Maria Aguilar to initiate a Case Management and issue Civil Penalties for the Annual Comprehensive Inspection conducted on 11/14/2024.

Per records review, the facility were cited for the same regulation on 11/27/2023 for California Code of Regulation (CCR) 87705(f)(1) Care of Persons with Dementia and civil penalty will be issued today, 11/15/2024 with the amount of $250.00 for repeating the same violation within 12 -month period.

In addition, the facility were cited for the same regulation on 11/27/2023 for California Code of Regulation (CCR) 87456 Evaluation of Suitability for Admission(a)(2) and civil penalty will be issued today, 11/15/2024 with the amount of $250.00 for repeating the same violation within 12 -month period.

An exit an interview was conducted, where this report, LIC809, LIC421FC, and Appeal Rights were discussed and provided to Licensee/Administrator Maria Aguilar.
Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187
DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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