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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423880
Report Date: 03/04/2021
Date Signed: 03/04/2021 02:19:39 PM

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:VISTA COVE AT CORONAFACILITY NUMBER:
336423880
ADMINISTRATOR:ALEJANDRA PERDOMOFACILITY TYPE:
740
ADDRESS:2600 SOUTH MAIN STREETTELEPHONE:
(951) 736-4780
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:49CENSUS: 14DATE:
03/04/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Alejandra PerdomoTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jennifer Semin made an unannounced visit to conduct a health and safety check. LPA met with Administrator, Alejandra Perdomo, toured the facility inside and out, interviewed staff, reviewed resident files and requested copies of pertinent documents.

LPA Semin and Ms. Perdomo toured the facility inside and out and did not observe any immediate health and safety concerns during the tour.

LPA and Ms. Perdomo discussed the late annual fees. Ms. Perdomo provided a payment receipt for annual fees paid on 9/11/2020. After much research, it appears the billing cycle is assessed annually on October 7, so the payment on 9/11/2020 was for the 2019 annual fee and late fee. There is currently a balance for the 2020 annual fee and late fee.
Ms. Perdomo stated she will contact the accounting department to notify them that the licensing annual fees are past due. LPA advised that the 2020 annual fee payment should be made no later than 3/8/2021.

LPA and Ms. Perdomo discussed the information in PIN 19-12-ASC regarding adding or changing a management company to an existing residential care facility for the elderly license. LPA provided Ms. Perdomo with a copy of PIN 19-12-ASC.

LPA requested Ms. Perdomo obtain and submit a copy of the agreement with the licensee and the property management company to CCL on or before 3/8/2021.

An exit interview was conducted where this report was discussed and provided to Ms. Perdomo.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
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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