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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880831
Report Date: 08/19/2024
Date Signed: 08/19/2024 02:14:31 PM

Document Has Been Signed on 08/19/2024 02:14 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AMETRINE HOUSEFACILITY NUMBER:
331880831
ADMINISTRATOR/
DIRECTOR:		TANISHA WILLIAMSFACILITY TYPE:
735
ADDRESS:6622 AMETRINE CTTELEPHONE:
(909) 615-7534
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 4CENSUS: 0DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:Administrator Tanisha WilliamsTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility for the purpose of an annual inspection. LPA met with the Administrator Tanisha Williams.

At this time, the facility does not have any clients. There are no clients in care due to the facility waiting for placement from Inland Regional Center. LPA toured the physical plant inside and out. The facility is clean and in good repair. Client bedrooms were appropriately furnished and had functional lighting. No hazards were observed. Cleaning supplies, medications, and sharps have designated areas where these items will be locked when not in use. The facility has operating smoke alarms and carbon monoxide detectors. The facility had a supply of nonperishable food items.

There were no staff or client files to inspect. LPA requested the administrator to notify the licensing department once the first client is admitted. A post-licensing inspection will be conducted once there are clients in care to ensure the facility is in compliance per Title 22 regulations.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the Administrator Williams.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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