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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198600306
Report Date:
03/24/2023
Date Signed:
03/24/2023 02:24:41 PM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
03/24/2023 02:24 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
CCLD Regional Office
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
ST. JUDES ELDER CARE
FACILITY NUMBER:
198600306
ADMINISTRATOR:
MARY ANN MCGEE
FACILITY TYPE:
740
ADDRESS:
103 BEN AVON COURT
TELEPHONE:
(909) 936-5424
CITY:
SAN DIMAS
STATE:
CA
ZIP CODE:
91773
CAPACITY:
6
CENSUS:
6
DATE:
03/24/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:49 PM
MET WITH:
Leony Dizon- Caregiver
TIME COMPLETED:
02:35 PM
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SUPERVISOR'S NAME:
Fernando Fierros
TELEPHONE:
(323) 981-3981
LICENSING EVALUATOR NAME:
Valeria Maldonado
TELEPHONE:
323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE:
03/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/24/2023
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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