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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800484
Report Date: 04/11/2023
Date Signed: 04/11/2023 12:16:43 PM

Document Has Been Signed on 04/11/2023 12:16 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
RIVERSIDE, CA 92507
FACILITY NAME:VIA GENOAFACILITY NUMBER:
331800484
ADMINISTRATOR:EDGINGTON, JOHN TFACILITY TYPE:
735
ADDRESS:47018 VIA GENOATELEPHONE:
(442) 324-0287
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 4CENSUS: 4DATE:
04/11/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Paulina Corona -AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Bernadette Allen met with Paulina Corona at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 04/11/2023 at 11:30 AM to initiate a Case Management Office Visit.

LPA Allen requested that Paulina come to the office to sign the amended complaint investigation documents that was conducted on 6/8/2021 control number 18-AS-20210607090221. Paulina also provided her documents to be added as the new administrator effective 11/2021. Copies were obtained to updated the facilities profile.

An exit interview was conducted where this report was discussed and a copy of the report 9099's and 9099-D was provided to Paulina Corona at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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