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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402223
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:42:39 PM

Document Has Been Signed on 06/09/2022 01:42 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
, 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:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Aileen Adams, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility to conduct a required annual visit. During this visit LPA is observing that the facility kitchen is under renovation. The facility plan for meal preparation is that all foods are being prepared off site at the sister facility Shelley's House down the street and delivered. The facility has a microwave and a well stocked refrigerator. Administrator was advised to submit a plan for during renovation for client safety, nutrition and regulation compliance. During this visit LPA toured the facility to assess for safety issues. None were found during this visit. An annual continuation visit will be conducted at another date.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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