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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427424
Report Date: 05/18/2023
Date Signed: 05/18/2023 10:19:45 AM


Document Has Been Signed on 05/18/2023 10:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ADEL'S VILLAFACILITY NUMBER:
336427424
ADMINISTRATOR:WILLIAMS, ADELAIDEFACILITY TYPE:
740
ADDRESS:1513 WESLEY STREETTELEPHONE:
(909) 278-1720
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:6CENSUS: 4DATE:
05/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Aminat Molade, House ManagerTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visit to the facility. LPA met with Aminat Molade, House Manager and discussed the purpose of the visit.

During today's visit, LPA amended a report regarding complaint control #56-AS-20230411153025 that was previously issued on 04/14/23.

No deficiencies were cited during the visit. An exit interview was conducted where this report was discussed and provided to the House Manager.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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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