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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603458
Report Date: 09/02/2021
Date Signed: 09/03/2021 10:47:47 AM

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:ARS FOUNTAIN HOMESFACILITY NUMBER:
198603458
ADMINISTRATOR:SANTOS JR., APOLONIO C.FACILITY TYPE:
740
ADDRESS:2668 FAWN CIRCLETELEPHONE:
(909) 575-7612
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: 0DATE:
09/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rowena Apolonio, LicenseeTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Linda Almaraz generated a subsequent pre-licensing report as a follow up to the initial pre-licensing visit conducted on August 25, 2021. During the initial pre-licensing visit applicant had a few corrections needed prior to obtaining a license.

The following items were reviewed and corrected:
  • Patio Furniture
  • Mattress Pads
  • COVID-19 screening visitor log
  • Hygiene supply
  • N95's and Face shields/goggles for at least 30 days
  • Lock/secure shed outside
  • Remove all debris/old furniture from the backyard
  • Closet space for all rooms
  • Post Theft and loss policy, and Labor laws for employees
  • First Aid Manual

LPA confirmed all items were corrected via pictures. A copy of this report was sent via email to Licensee, Rowena Apolonio for a signature.

Accordingly, LPA will submit a copy of this Facility Evaluation Report to the Central Applications Unit (CAU) for review. If Licensee Applicant Representative has questions regarding the status of the application, they have been instructed to communicate with their CAU Analyst assigned to process their application.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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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