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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402223
Report Date: 11/03/2021
Date Signed: 11/03/2021 02:59:10 PM

Document Has Been Signed on 11/03/2021 02:59 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
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:
11/03/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee, Rodante CanlasTIME COMPLETED:
01:10 PM
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An Informal Meeting was conducted today November 3, 2021 virtually via Microsoft Teams to discuss incident involving resident # 1(R1) and staff # 1(S1) occurring on November 7,2019. Present at today’s meeting were: Administrator, Aileen Adams,Licensee's, Rodante Canlas,and Delle Canlas, Staff, Tiffany Canlas, Licensing Program Manager, Joel Esquivel, and Licensing Program Analyst, David Cuevas.

During today’s conference, the following matter was discussed:

(2) Type A SUBSTANTIATED allegations, Visit conducted on 1/9/20 for:
  • Staff physically restrained resident
  • Staff hit resident.
  • Residents Personal Rights
  • Licensee's, Mr and Ms. Canlas were offered to participate in Technical Support Program (TSP) during todays informal meeting that is offered through DSS.


Licensee, accepted to participation to TSP program during this informal meeting, referral will be made by LPA Cuevas. During todays informal meeting Licensee, agreed to be in compliance to the items listed above and implement appropriate measures moving forward to avoid such occurrences.

An exit interview was conducted where this report was discussed and provided to the licensee. LPA emailed copy of the report for signature and requested the signed copy to be emailed back. Administrator agreed.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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