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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426224
Report Date: 07/25/2022
Date Signed: 07/25/2022 01:37:42 PM


Document Has Been Signed on 07/25/2022 01:37 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:DOVE TREE MANORFACILITY NUMBER:
366426224
ADMINISTRATOR:SOSNOVSKY, EVA FEFACILITY TYPE:
740
ADDRESS:3991 DOVE TREE AVE.TELEPHONE:
(909) 441-7891
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY:6CENSUS: 4DATE:
07/25/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Leonard Dolliente, care providerTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit at the facility for the purpose of conducted a Plan of Correction (POC) visit. LPA met with care staff Leo, who was informed of the purpose of the visit.

On 6/23/2022 the facility was issued a deficiency with a plan of correction date of 7/11/2022. LPA interviewed care staff who confirmed that they were not scheduled as live-in staff from 7/1/22 through 7/17/22 until the facility was able to provide private accommodations on 7/18/2022.

The facility will receive a Letter of Deficiency Citation Cleared for the deficiency cleared during today's inspection. An exit interview was conducted where a copy of this report was discussed with and provided to Mr. Dolliente.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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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