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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424665
Report Date: 08/26/2021
Date Signed: 08/26/2021 10:34:13 AM

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:CHARDONNAY HILLS CARE HOMEFACILITY NUMBER:
336424665
ADMINISTRATOR:RANDALL T. GRINDLEFACILITY TYPE:
740
ADDRESS:31416 CHEMIN CHEVALIERTELEPHONE:
(951) 506-4950
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY:6CENSUS: 6DATE:
08/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Maribel BattadTIME COMPLETED:
10:33 AM
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Elecia Weathersby (LPA) made an unannounced visit to the facility to commence a Health and Safety check and assess recent administration changes at the facility.

LPA conducted interviews with 3 of 3 staff, acting Administrator Sam Awad, caregiver Maribel Battad, and caregiver, Norma Martinez. LPA conducted a brief tour of the facility. LPA observed 6 residents in care. The facility was also equipped with sufficient food, and hygiene supplies. Staff shared proof of vaccination for 5 of 6 residents.

LPA Weathersby observed no health and safety concerns at the time of visit. Based on observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to acting Administrator Sam Awad at the conclusion of the inspection
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Elecia WeathersbyTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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