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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334812819
Report Date: 11/23/2021
Date Signed: 11/23/2021 03:20:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:FSA-HEMLOCK CDCFACILITY NUMBER:
334812819
ADMINISTRATOR:DANIELA PEREZFACILITY TYPE:
850
ADDRESS:23270 HEMLOCK AVE.TELEPHONE:
(951) 243-3192
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:110CENSUS: 30DATE:
11/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Mary Hampton/Program Specialist & Leslie Cox/Interim DirectorTIME COMPLETED:
03:15 PM
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On the above date and time listed above, LPA Susan Brewer, arrived at the facility unannounced for the purpose of conducting a Case Management in response to the receipt of an Unusual Incident Reported by the Licensee on 11/16/2021. LPA was greeted by Mentor Coach/Interim Director Leslie Cox, stated the purpose of the visit and conducted a COVID-19 Pre-Screening. L. Cox, who granted entry into the facility. A census was taken of 30 children present and 7 staff, with another staff arriving at approximately 12:10 PM, totalling 8 staff. Mary Hampton arrived at approximately 1:25 PM.

During the inspection, LPA Susan Brewer, reviewed and obtained staff/children's records, made observations and was unable to conduct interviews with all pertinent parties. More information is needed to complete the review and further information will be needed. Upon completion of the review the outcome and/or recommendations will be provided to the Licensee. An exit interview was conducted and a copy of this report was left with the Program Specialist Mary Hampton. A Notice of Site Visit was provided to the Program Specialist Mary Hampton and posted in the presence of the LPA.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Susan BrewerTELEPHONE: (951) 970-0343
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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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