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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530048
Report Date: 12/09/2024
Date Signed: 12/09/2024 01:56:08 PM

Document Has Been Signed on 12/09/2024 01:56 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:EMMA'S CASE ARF INC.FACILITY NUMBER:
335530048
ADMINISTRATOR/
DIRECTOR:		CHAVEZ, ALIX GARCIAFACILITY TYPE:
735
ADDRESS:20043 CASE STTELEPHONE:
(909) 316-9555
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 4CENSUS: 2DATE:
12/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Alex Garcia, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 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
On 12/09/2024 at 1:15 PM Licensing Program Analyst (LPA) Eldin Serrano met with the administrator/licensee Alex Garcia. LPA explained the purpose of the visit to the administrator. The purpose of the visit is only to interview resident #1 (R1) regarding complaint # 56-AS-20241107111607. Interviewed R1 and got the information needed.

A copy of this form LIC809 was provided to the administrator Alex Garcia.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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