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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426029
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:15:29 PM


Document Has Been Signed on 10/25/2022 12:15 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:CALOAKS SENIOR LIVINGFACILITY NUMBER:
336426029
ADMINISTRATOR:AMELIA ALADINFACILITY TYPE:
740
ADDRESS:3891 POLK STREETTELEPHONE:
(951) 689-6162
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:74CENSUS: 55DATE:
10/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Melissa Bridges, LVN
TIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Amy Goldenberg and Amber Coleman are conducting an unannounced case management visit. The purpose of this visit is to conduct inquiry in to health and safety care concerns of residents.

During this visit LPAs conducted a brief tour and spoke with random residents. Tour included assessing the food supply. LPAs reviewed five (5) resident records, interviewed five (5) residents, reviewed one (1) residents medication treatment records and met with the facility administrator Amy Aladdin and LVN Melissa Bridges.

Based on the information obtained through review of record, tour of the facility and interviews there are no deficiencies being cited per Title 22, Division 6 of the California code of regulations.

This report was reviewed with and a copy was provided to the facility representatives.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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