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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
331800484
Report Date:
11/08/2021
Date Signed:
11/08/2021 09:23:31 AM
Document Has Been Signed on
11/08/2021 09:23 AM
- 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
RIVERSIDE
,
CA
92507
FACILITY NAME:
VIA GENOA
FACILITY NUMBER:
331800484
ADMINISTRATOR:
EDGINGTON, JOHN T
FACILITY TYPE:
735
ADDRESS:
47018 VIA GENOA
TELEPHONE:
(760) 262-5957
CITY:
INDIO
STATE:
CA
ZIP CODE:
92201
CAPACITY:
4
CENSUS:
3
DATE:
11/08/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
08:30 AM
MET WITH:
Paulina Corona
TIME COMPLETED:
09:30 AM
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On 11/8/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of obtaining a signature for complaint # 18-AS-20210607090221.
A copy of this report was provided to John Edgington via email.
SUPERVISORS NAME
:
Nedra Brown
LICENSING EVALUATOR NAME
:
Shaunte Henry
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/08/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/08/2021
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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