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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
364840169
Report Date:
09/16/2019
Date Signed:
09/23/2019 01:21:48 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:
EASTER SEALS CHILD DEVELOPMENT CENTER
FACILITY NUMBER:
364840169
ADMINISTRATOR:
REGINA HERBERTSON
FACILITY TYPE:
850
ADDRESS:
9950 MONTE VISTA
TELEPHONE:
(909) 626-1700
CITY:
MONTCLAIR
STATE:
CA
ZIP CODE:
91763
CAPACITY:
105
CENSUS:
66
DATE:
09/16/2019
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
08:45 PM
MET WITH:
R. Herbertson
TIME COMPLETED:
11:00 PM
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****ELECTRONIC COPY ONLY** SIGNATURE ON HANDWRITTEN REPORT*****************
Licensing Program Analyst, Nelson Zuniga conducted an onsite inspection.
An exit interview was held.
SUPERVISOR'S NAME:
Gilbert Sena
TELEPHONE:
(951) 782-4844
LICENSING EVALUATOR NAME:
Nelson Zuniga
TELEPHONE:
(951) 782-6634
LICENSING EVALUATOR SIGNATURE:
DATE:
09/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/16/2019
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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