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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427235
Report Date: 01/10/2024
Date Signed: 01/10/2024 01:57:04 PM


Document Has Been Signed on 01/10/2024 01:57 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:CORONA RESIDENTIAL CARE CENTER LLCFACILITY NUMBER:
336427235
ADMINISTRATOR:AHARON STRIKSFACILITY TYPE:
740
ADDRESS:1400 CIRCLE CITY DRTELEPHONE:
(951) 735-0252
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:125CENSUS: 88DATE:
01/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Maria "Mary" Gonzales- Administrator AssistantTIME COMPLETED:
02:06 PM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced case management visit to the facility and was met by Administrator Assistant Maria “Mary” Gonzales.

Today’s visit was conducted to follow up on a self-reported incident regarding Resident R1 that occurred at the facility on 12/29/2023. During today’s visit, LPA interviewed staff and obtained documents relating to the incident. No deficiencies or citations were issued on this visit.

An exit interview was conducted where this report (LIC809) and LIC811 were discussed and provided to Administrator Assistant Maria “Mary” Gonzales.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
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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