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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530081
Report Date: 03/07/2023
Date Signed: 03/20/2023 10:00:29 AM

Document Has Been Signed on 03/20/2023 10:00 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GUS RESIDENTIAL HOME INC.FACILITY NUMBER:
335530081
ADMINISTRATOR:MOMODU, AUGUSTAFACILITY TYPE:
735
ADDRESS:11466 LYLE LNTELEPHONE:
(305) 397-1328
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 4CENSUS: 0DATE:
03/07/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Augusta MomoduTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Chitgian conducted an announced visit to the facility to conduct a pre-licensing inspection. LPA met with Augusta Momodu.

Based on observations made by the LPA, the pre-licensing inspection is not able to be completed at this time due to inconsistencies on the floor plan. Submitted floor plan layout has indicated one(1) bathroom. Walk-through of the facility shows to have two(2) bathrooms on the first floor layout.

COMP III was completed during the visit. LPA and licensee will reschedule a follow up inspection once correction has been completed.

Pre-Licensing is incomplete. A follow up Pre-Licensure LIC 809 will be generated upon completion.

An exit interview was conducted where is report was discussed and provided to Augusta Momodu.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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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