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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426688
Report Date: 06/14/2024
Date Signed: 06/14/2024 02:32:13 PM


Document Has Been Signed on 06/14/2024 02:32 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:HEARTLAND MANORFACILITY NUMBER:
336426688
ADMINISTRATOR:AHMED QASIMFACILITY TYPE:
740
ADDRESS:178 W. PENDLETON ROADTELEPHONE:
(951) 849-7750
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:22CENSUS: 15DATE:
06/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Grace Reyes - House ManagerTIME COMPLETED:
02:38 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced follow-up facility visit to gather information pertaining complaint # 56-AS-20240502114053 investigation. LPA met with Grace Reyes, House Manager, and discussed the purpose of the visit.

During today’s visit, LPA obtained copies of relevant documents.

An exit interview was conducted where this report was discussed and a copy of this report was provided to the House Manager at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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