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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402223
Report Date: 09/30/2021
Date Signed: 10/01/2021 11:37:50 AM

Document Has Been Signed on 10/01/2021 11:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AMY'S HOUSEFACILITY NUMBER:
336402223
ADMINISTRATOR:AILEEN ADAMSFACILITY TYPE:
735
ADDRESS:3731 CALIFORNIA AVETELEPHONE:
(951) 372-0554
CITY:NORCOSTATE: CAZIP CODE:
91760
CAPACITY: 4CENSUS: 4DATE:
09/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH: Administrator,Aileen AdamsTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Cuevas met with Administrator, Aileen Adams for the purpose of amending report for complaint report 18-AS-20191108085934. LPA Cuevas went over the amended report with Administrator, Aileen Adams and provided copies of both the amended complaint report as well as this report.

An exit interview was conducted and a copy of all reports was provided to Administrator, Aileen Adams
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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