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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426029
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:34:23 PM


Document Has Been Signed on 02/24/2023 12:34 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: 57DATE:
02/24/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Amelia AladinTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/24/2023 at 11:30 AM, unannounced for a collateral visit on a complaint investigation to interview residents and staffs regarding complaint control number 56-AS-20230214082530. During this visit, LPA Brown was met by facility Administrator Amelia Aladin.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided to Administrator Aladin.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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