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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412373
Report Date: 08/29/2023
Date Signed: 08/29/2023 10:12:10 AM

Document Has Been Signed on 08/29/2023 10:12 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JOHN, TRACI, & COFACILITY NUMBER:
336412373
ADMINISTRATOR:SCHWAB, TRACIFACILITY TYPE:
735
ADDRESS:3680 ANCHORAGE ST.TELEPHONE:
(951) 392-2213
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 5CENSUS: 4DATE:
08/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:House Manager Cristhian RodriguezTIME COMPLETED:
10:30 AM
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On 8/29/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct a Case Management visit for the purpose of obtaining signatures for an amended report. LPA was greeted and granted entry by House Manager Cristhian Rodriguez who was informed of the purpose of the visit. During today's visit, LPA was informed that clients were at day program.

During today’s visit, LPA conducted a tour of the facility and did not observe any issues or concerns.

The amended report delivered today is an amended version of the original report due to database issues experienced on 7/24/2023, which did not capture signatures or revisions made to the original report.

A copy of this report was reviewed and provided to House Manager Rodriguez.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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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