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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603879
Report Date: 10/18/2023
Date Signed: 10/18/2023 05:16:16 PM

Document Has Been Signed on 10/18/2023 05:16 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ADAM'S HELENA ARFFACILITY NUMBER:
374603879
ADMINISTRATOR:CROW, DARAFACILITY TYPE:
735
ADDRESS:4041 HELENA STREETTELEPHONE:
(760) 451-0536
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 4DATE:
10/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:House Manager, Sonia
Villegas		TIME COMPLETED:
03:00 PM
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On 10/18/23 Licensing Program Analysts (LPA) Cheryl Goodrich made an unannounced Case Management visit to the facility to gather information regarding the First Choice Transportation Incident that took place on 09/25/23 and to check on the safety and well being of resident Austin Matthews.

LPA met with House Manager, Sonia Villegas to discuss the incident, obtain First Choice Transportation contact information and more information about the incident and check on the status of the resident. First Choice Transportation Driver Denise is no longer driving for facility. The facility's new driver is Rodger.

An exit interview was conducted and a copy of this report was provided to House Manager, Sonia Villegas.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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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