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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610586
Report Date:
08/28/2024
Date Signed:
08/28/2024 05:26:27 PM
Document Has Been Signed on
08/28/2024 05:26 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
N LA & CEN COA AC/SC
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
PETRA RESIDENTIAL INC.
FACILITY NUMBER:
197610586
ADMINISTRATOR/
DIRECTOR:
MOLOCK, BRUCE E. JR
FACILITY TYPE:
735
ADDRESS:
44540 TAHOE WAY
TELEPHONE:
(949) 594-9104
CITY:
LANCASTER
STATE:
CA
ZIP CODE:
93536
CAPACITY:
4
CENSUS:
0
DATE:
08/28/2024
TYPE OF VISIT:
Prelicensing
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:
Bruce Molock E. JR
TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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A follow up Pre-licensure LIC809 was generated upon resolution of deficiencies.
Licensing Program Analyst (LPA) Evelin Rios received a telephone call at 2:22 p.m. from applicant via facility telephone. Facility telephone is now operational.
Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete.
Report signed and issued.
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Evelin Rios
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
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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