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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881019
Report Date: 09/20/2021
Date Signed: 09/20/2021 10:43:19 AM

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
RIVERSIDE, CA 92507
FACILITY NAME:WILDWOOD CANYON VILLAFACILITY NUMBER:
361881019
ADMINISTRATOR:OSORIO, JULIUSFACILITY TYPE:
740
ADDRESS:33951 COLORADO STTELEPHONE:
(909) 446-0405
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:130CENSUS: 62DATE:
09/20/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Business Service Director, Pricilla MancillaTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to the facility for the purpose of completing a Health & Safety check in conjunction with complaint control # 18-AS-20210913125516. LPA met with Business Service Director, Pricilla Mancilla and explained the purpose of the inspection.

LPA toured the facility inside and out. No imminent health/safety concerns observed at the time of visit. LPA observed no health/safety hazards inside the facility. LPA inspected the outside perimeter of the facility and observed no health/safety hazards. There was a sufficient amount of staff present at the facility to provide care for residents. LPA inspected facility food supplies and observed an adequate supply of perishable and non-perishable food. Medications, sharps, and cleaning supplies were locked and inaccessible to residents. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies and a sufficient supply of Personal Protective Equipment (PPE). The needs of the residents in care appeared to be met during the inspection.

An exit interview was conducted where this report was discussed and provided to Ms. Mancilla.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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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