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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423880
Report Date: 04/22/2021
Date Signed: 04/22/2021 12:55:11 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: 12DATE:
04/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alejandra PerdomoTIME COMPLETED:
01:16 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.

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 documents that were requested during a meeting that was held in the RO office on 3/25/2021.
CCLD staff requested:
1.) documentation of the transfer of the license
2.) finalization of the action filed by the court regarding the breach of the tenant's lease agreement
3.) a copy of the agreement between Beechan Health and Corona RCFE LLC
4.) LIC309- Administration Organization
5.) LIC308- Designation of Facility Responsibility.

CCLD has not received these documents from the licensee. Ms. Perdomo contacted licensee Chiam Raskin via text message and via telephone. Mr. Raskin stated he will send all the required documentation via email to jennifer.semin@dss.ca.gov by end of business today 4/22/2021.

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: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
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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