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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881099
Report Date: 10/03/2024
Date Signed: 10/03/2024 09:44:07 AM

Document Has Been Signed on 10/03/2024 09:44 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:RODRIGUEZ FAMILY HOMEFACILITY NUMBER:
331881099
ADMINISTRATOR/
DIRECTOR:
IVETTE MUNOZFACILITY TYPE:
735
ADDRESS:11878 RIDGECREST DRTELEPHONE:
(951) 858-5709
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 2CENSUS: 2DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:IVETTE MUNOZTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPAs) Beena Singh and Paola Guerrero made an announced required case management visit at the above referenced facility. LPA was granted access to the home by Facility Administrator IVETTE MUNOZ.

Licensing Program Analyst (LPAs) Beena Singh and Paola Guerrero conducted an announced visit to the facility for the purpose of increasing the capacity, per the licensee's request. Upon arrival LPA met with Administrator Ivette Munoz and was granted entry into the facility.

The licensee requested a capacity increase from two (2) ambulatory to three (3) ambulatory. The fire clearance request was approved on 09/11//2024.

There is a facility sketch on file with designation of capacity for each room. The licensee is advised that the noted designated capacity for each room is to remain in compliance. LPA obtained a copy of new updated facility sketch from the licensee.

LPA observed that the client bedrooms were appropriately furnished and had functional lighting. The physical plant is ready for an increase in capacity. LPA will update the facility's file and issue a new license to the facility.

There are currently two (2) clients in care.

During this Inspection no deficiencies were issued,an exit interview was conducted where this report was discussed and provided to the administrator, Ivette Munoz.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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