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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002831
Report Date: 02/22/2022
Date Signed: 02/22/2022 03:48:36 PM

Document Has Been Signed on 02/22/2022 03:48 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PEOPLE'S CARE KRANS COURTFACILITY NUMBER:
345002831
ADMINISTRATOR:ANDRES, JUANFACILITY TYPE:
735
ADDRESS:8530 KRANS COURTTELEPHONE:
(909) 287-3557
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 0DATE:
02/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cristin Nicoletti, Project ManagerTIME COMPLETED:
02:00 PM
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LPA (Licensing Program Analyst) Williams and LPA Keosavang arrived on Tuesday, February 22, 2022 to conduct the prelicensing inspection. Prior to the visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 masks.

LPAs completed the prelicensing inspection domain with Project Manager Cristin and Administrator Juan Andres. LPAs toured the facility and insured all rooms had the required furniture (one room is set up and Licensee will call LPA once remaining furniture has been transported). LPAs requested that Project Manager Cristin call LPA once furniture has arrived and been set up in all bedrooms. At this time LPA will return for a post-licensing visit.

LPAs observed that the facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and final reiew of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Component III was waived. Upon review of updated approved facility sketch, LPAs will notify CAB that the facility is ready for licensure.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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