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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881368
Report Date: 01/14/2025
Date Signed: 01/14/2025 10:36:34 AM

Document Has Been Signed on 01/14/2025 10:36 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LEGACY OF HEMET 1, THEFACILITY NUMBER:
331881368
ADMINISTRATOR/
DIRECTOR:		KELLOGG, MICHELLEFACILITY TYPE:
740
ADDRESS:320 S SAN JACINTO STTELEPHONE:
(951) 765-1840
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 16CENSUS: 7DATE:
01/14/2025
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Haley Suarez-Med-Tech SupervisorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Debbie Palacios arrived unannounced to the facility to conduct a collateral visit in conjunction with complaint investigation at another facility and completely unrelated to this facility. LPA met with Haley Suarez and explained the nature of today’s visit.

During today’s visit, LPA reviewed staff records. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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