<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881543
Report Date: 05/15/2024
Date Signed: 05/16/2024 04:39:57 PM

Document Has Been Signed on 05/16/2024 04:39 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:UNITED IN CHANGE - AVENIDA HOUSEFACILITY NUMBER:
331881543
ADMINISTRATOR/
DIRECTOR:		MONTGOMERY, MONICAFACILITY TYPE:
735
ADDRESS:26452 AVENIDA DE LA PAZTELEPHONE:
(951) 777-9118
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 0DATE:
05/15/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH: Etta Simpson and Monica Montgomery TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
COMP II by CAB successfully completed

Facility Type: ARF
Application Type: INTL
Capacity: 4
Census : 0
Method: Telephone call with CAB
COMP II Participants: Etta Simpson (Licensee), Monica Montgomery (Administrator), & Tammy Edwards, (Analyst).

Licensee & administrator participated in COMP II via Telephone call with CAB Analyst. Identification of licensee/ administrator was verified by confirming driver’s license numbers. During COMP II, licensee/ administrator confirmed the understanding of Title 22. Component II was successfully completed. Licensee/administrator were advised to email signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed licensee's/administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Tammy Edwards
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1