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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910676
Report Date: 01/26/2023
Date Signed: 01/26/2023 02:17:01 PM

Document Has Been Signed on 01/26/2023 02:17 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:J & S BOARD & CAREFACILITY NUMBER:
330910676
ADMINISTRATOR:SUSAN PRIORFACILITY TYPE:
735
ADDRESS:11334 58TH STREETTELEPHONE:
(951) 360-1287
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 6CENSUS: 4DATE:
01/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Carmencita TIME COMPLETED:
03:00 PM
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0830: Licensing Program Analyst (LPA) Amy Goldenberg arrived to the location to conduct a case management visit. LPA knocked on the door and there was no answer. LPA attempted to contact the facility staff by the available numbers. There was no answer and no voicemail. LPA will return at a later time to complete this visit.


1400: LPA Amy Goldenberg conducted a case management visit. The purpose of this visit is to deliver an amended LIC 809D page initially delivered on 12/07/2022. LPA reviewed the amended LIC 9099D dated 12/7/2022 and this LIC 809 report dated 1/26/2023. A copy of both reports were provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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