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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501798
Report Date: 01/25/2024
Date Signed: 01/25/2024 05:48:21 PM


Document Has Been Signed on 01/25/2024 05:48 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:ABILITY FIRSTFACILITY NUMBER:
191501798
ADMINISTRATOR:JULIE MARTINFACILITY TYPE:
840
ADDRESS:480 SOUTH INDIAN HILL BLVD.TELEPHONE:
(909) 621-4727
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:58CENSUS: 4DATE:
01/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Julie MartinTIME COMPLETED:
02:30 PM
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On January 25, 2024, Licensing Program Analyst (LPA) Carolyn Tuba conducted a case management inspection due to an incident that occurred at the facility on 1/23/2024. LPA met with Director, Julie Martin and additional administrators. LPA obtained a census of 4 children with 2 staff. LPA obtained information of the incident from the Director and additional administrators, as well as documentation.

The incident was reported to the Department within the required 24 hours of occurrence. The incident consisted with a participant/student leaving the facility.


Based on all the information obtained, LPA will require to conduct further interviews with staff. LPA reviewed participant’s file and took photos and measurements.

No deficiencies were cited during today’s inspection.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director, Julie Martin.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Carolyn TubaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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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