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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603585
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:41:26 PM


Document Has Been Signed on 11/21/2023 02:41 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:ALVIN'S HOMECAREFACILITY NUMBER:
374603585
ADMINISTRATOR:JOHN BULAOROFACILITY TYPE:
740
ADDRESS:724 DRIFTWOOD LANETELEPHONE:
(760) 990-4694
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:6CENSUS: 5DATE:
11/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Caregiver Teresita PanolinoTIME COMPLETED:
02:46 PM
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Licensing Program Analysts (LPAs) Jesse Gardner and Javina George made an unannounced visit to the property to commence a complaint investigation, refer to 18-AS-20231117141500 for further information.

Upon arrival, LPAs met with Caregiver Teresita Panolino and toured the facility. LPAs found 5 residents in care, and 5 staff inside the facility.

Record review indicated that the facility is currently licensed under License #374603585. Record review further indicated that the property sold on 10/27/2023 to a new owner; however, the Licensee still maintains their license by physically being at the facility on a daily basis at a minimum of 20 hours per week.

Licensee stated that notification was not made to notify the Department of the sale of property. Licensee agrees to provide a lease agreement with the new owner by the close of business on 11/22/2023. A technical violation was issued to document the regulatory violation.

Additionally, interview with Licensee stated that the resident's responsible parties were not notified of the sale of property. Licensee indicated that notification was planned to be made after the new owner of the property submits their license application. A technical violation was issued, and the Licensee explained that notification would be made to the resident's responsible parties today, and the Department would be sent proof of such.

An exit interview was conducted where a copy of this report was provided along with copies of the technical violations.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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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