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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604135
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:28:00 PM


Document Has Been Signed on 04/12/2023 02:28 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:SHADOWRIDGEFACILITY NUMBER:
374604135
ADMINISTRATOR:BEATRICE BRACAMONTEFACILITY TYPE:
740
ADDRESS:2354 WATSON WAYTELEPHONE:
(760) 295-3888
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:48CENSUS: 37DATE:
04/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Veronica Delval, LVN TIME COMPLETED:
02:35 PM
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On 4/12/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit regarding two residents having an altercation. LPA met with LVN, Veronica Delval who was informed of the purpose of the visit.

During the visit, LPA toured the facility, interviewed staff and resident. During the interview, LPA found that medical attention was provided to resident #2 and resident #1 was removed from the facility and is currently on a psychiatric hold. LPA found no health and safety issues. No deficiencies noted at the time of visit.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Veronica Delval.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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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