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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880906
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:18:39 PM

Document Has Been Signed on 09/04/2024 03:18 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A & J RESIDENTIAL CARE FACILITYFACILITY NUMBER:
331880906
ADMINISTRATOR/
DIRECTOR:		YOUNES, AMIRRAFACILITY TYPE:
735
ADDRESS:1229 KELLEY AVETELEPHONE:
(650) 656-7941
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: 6DATE:
09/04/2024
TYPE OF VISIT:Case Management - Infectious Disease OutbreakUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Areil GaliciaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Mary Rico made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility. LPA Rico met with staff Areil Galicia explained the reason for the visit.

The Health and Safety check included overall observation of the facility inside, and outside, including food supply, physical plant, and the clients in care.

LPA Rico conducted a (6) client interviews.

Based on the observations made during today’s visit,no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809 was discussed and provided to staff Areil Galicia.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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