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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604338
Report Date: 09/01/2023
Date Signed: 09/01/2023 10:37:44 AM

Document Has Been Signed on 09/01/2023 10:37 AM - 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:MOLLY'S HOUSEFACILITY NUMBER:
374604338
ADMINISTRATOR:POWELL, DUSHAWN A.FACILITY TYPE:
735
ADDRESS:15260 VILLA SIERRA RDTELEPHONE:
(951) 473-3692
CITY:VALLEY CENTERSTATE: CAZIP CODE:
92082
CAPACITY: 4CENSUS: 4DATE:
09/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Staff, Natali SoriaTIME COMPLETED:
10:45 AM
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On 9/1/2023, Licensing Program Analyst (LPA) Arreola made a visit to the facility in order to deliver an amended report.

Upon arrival, LPA rang and knocked and rang door bell and received no answer. LPA contacted both the administrator Dushawn Powell and staff, Natali Soria who stated that the clients were on an outing and would not be able to return until 1pm due to travel time. LPA informed the staff they would email the report to them and needed to provide signature no later than 9/1/2023 COB 5pm.

LPA left this report at the facility and conducted an exit interview with staff, Natali Soria over the phone.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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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