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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
331800202
Report Date:
12/06/2024
Date Signed:
12/06/2024 04:22:12 PM
Document Has Been Signed on
12/06/2024 04:22 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
RIVERSIDE ASC
,
1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE
,
CA
92507
FACILITY NAME:
KALPESH HOME
FACILITY NUMBER:
331800202
ADMINISTRATOR/
DIRECTOR:
CHURCH, CINDY
FACILITY TYPE:
735
ADDRESS:
944 KALPESH DRIVE
TELEPHONE:
(951) 487-1873
CITY:
SAN JACINTO
STATE:
CA
ZIP CODE:
92583
CAPACITY:
6
CENSUS:
4
DATE:
12/06/2024
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:18 PM
MET WITH:
Wendy Lesly, house manager
TIME VISIT/
INSPECTION COMPLETED:
02:19 PM
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SUPERVISORS NAME
:
Rikesha Stamps
LICENSING EVALUATOR NAME
:
Seo Jeon
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/06/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/06/2024
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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