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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
364840450
Report Date:
03/03/2022
Date Signed:
03/03/2022 10:02:01 AM
Document Has Been Signed on
03/03/2022 10:02 AM
- 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
,
3737 MAIN ST., SUITE 700
RIVERSIDE
,
CA
92501
FACILITY NAME:
CASA RAMONA INC
FACILITY NUMBER:
364840450
ADMINISTRATOR:
TABITHA THUR
FACILITY TYPE:
850
ADDRESS:
1633 W. 5TH STREET
TELEPHONE:
(909) 889-0011
CITY:
SAN BERNARDINO
STATE:
CA
ZIP CODE:
92411
CAPACITY:
45
CENSUS:
14
DATE:
03/03/2022
TYPE OF VISIT:
Case Management - Deficiencies
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Tabitha Thur
TIME COMPLETED:
10:15 AM
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LPAs Zeigler and Zeron conducted a Case Management visit to follow up on deficiencies cited on 02/23/2022. The nature of the visit was discussed and LPAs were granted entry into the facility. Facility was toured and census was taken.
LPAs reviewed and observed completed corrections and received and reviewed work order requests for remaining items.
POCs are being cleared during this visit.
An exit interview was conducted and a copy of this report and NOS was issued.
SUPERVISOR'S NAME:
Kimberly Williams
TELEPHONE:
(951) 248-0228
LICENSING EVALUATOR NAME:
Taadhimeka Zeigler
TELEPHONE:
(951) 970-7385
LICENSING EVALUATOR SIGNATURE:
DATE:
03/03/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/03/2022
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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