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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425633
Report Date: 07/28/2023
Date Signed: 07/28/2023 03:25:23 PM

Document Has Been Signed on 07/28/2023 03:25 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NELSON ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
336425633
ADMINISTRATOR:ALAN ALIAN JR.FACILITY TYPE:
735
ADDRESS:2216 FIELDING RD.TELEPHONE:
(951) 224-9068
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 6DATE:
07/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Caregiver Victorio EstevesTIME COMPLETED:
03:40 PM
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
On 7/28/2023 at 3:10 p.m. Licensing Program Analyst (LPA) Janette Romero conducted an unannounced health and safety visit to the facility. LPA met with Caregiver Victorio Esteves who was informed of the purpose of the visit.

At the time of the visit there were three (3) staff and (5) clients present. Staff present possessed a criminal background clearance and were associated to the facility. LPA conducted a tour of the facility's interior and exterior. LPA observed the staff room, clients rooms, bathrooms, outdoor yard/patio, kitchen and dining area. LPA observed the facility had more than a 2-day supply of perishable food items and 7-day supply of non-perishable food items. LPA observed clients in their rooms and common areas.

During this visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was discussed and provided to Caregiver Esteves.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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