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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364817288
Report Date: 12/11/2019
Date Signed: 12/11/2019 03:14:31 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:RUSD-MENTONE ELEMENTARY SCHOOLFACILITY NUMBER:
364817288
ADMINISTRATOR:SUE BUSTERFACILITY TYPE:
850
ADDRESS:1320 CRAFTON AVENUE,K-1TELEPHONE:
(909) 794-8610
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:24CENSUS: 18DATE:
12/11/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Amy PryTIME COMPLETED:
03:20 PM
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On 12/11/2019, Licensing Program Manager (LPM) Kimberly Williams and Licensing Program Analyst (LPA) Destinee Hogue arrived at the facility to amend Complaint Investigation Reports dated 11/04/2019. LPM and LPA toured the facility, took census and met with Assistant Principal, Amy Pry.

No deficiencies were cited during inspection 12/11/2019.

A notice of site visit was issued, and LPA verified that it was posted in a prominent location at the facility before leaving. Notice of Site Visit shall be posted for 30 day's.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019
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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