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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881185
Report Date: 03/02/2022
Date Signed: 03/02/2022 12:32:47 PM

Document Has Been Signed on 03/02/2022 12:32 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
RIVERSIDE, CA 92507
FACILITY NAME:ALBERTO CARE CENTERFACILITY NUMBER:
361881185
ADMINISTRATOR:LAYGO, ALLISONFACILITY TYPE:
735
ADDRESS:13542 LAKOTA ROADTELEPHONE:
(951) 347-0895
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
03/02/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Allison Laygo-Administrator and
Adrian Laygo- Assistant Administrator		TIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate was submitted to the Central Applications Unit (CAU) on 06/16/2021. Fire Clearance was granted 08/31//2021. LPA Allen observed the following:

Structure: Facility was a single story house with six (4) resident bedrooms, 5 bathrooms, living room, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: All bedrooms were adequately furnished with mattress, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by LPA at 121. F.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments have allocated locked spaces. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.
Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Yards/Outside: The back was completed was a patio set under shaded area There were no obstructions or bodies of water observed anywhere on the property.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALBERTO CARE CENTER
FACILITY NUMBER: 361881185
VISIT DATE: 03/02/2022
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Garage/laundry/leisure: Laundry area with washer and dryer are available. Laundry detergents and cleaning solutions were secured. There was an outside recreational leisure area set up for staff and client use. There is no garage.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster and clients rights are posted in clients bedrooms.

General items: Smoke/carbon monoxide detectors were tested and operational. LPA tested facility phone and it was verified to be operational by LPA.

COMPONENT III was reviewed by the applicants during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time. This report was reviewed with an a copy was provided to the applicants.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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