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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426750
Report Date: 05/22/2023
Date Signed: 05/22/2023 04:49:36 PM

Document Has Been Signed on 05/22/2023 04:49 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PARTNERS N CARE-CARE HOMEFACILITY NUMBER:
336426750
ADMINISTRATOR:VAUGHAN, BEVERLEEFACILITY TYPE:
740
ADDRESS:5920 COPPERFIELD AVETELEPHONE:
(951) 213-6591
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 6DATE:
05/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Kerin Vaughn, Facility ManagerTIME COMPLETED:
04:55 PM
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On 5/22/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct a case management visit to deliver an Immediate Exclusion notice of staff #1. At the time of visit, LPA met with Facility Manager, Kerin Vaughn who was informed of the purpose of the visit.

During the visit LPA toured the facility inside and out and didn’t observe staff #1 in the facility. LPA was informed staff #1 last worked for the facility in 2/2023. LPA gave Kerin Vaughn the Immediate Exclusion notice of staff #1. No citation was issued during today’s visit.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Kerin Vaughn.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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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