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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360900100
Report Date: 05/16/2023
Date Signed: 05/16/2023 08:38:38 AM


Document Has Been Signed on 05/16/2023 08:38 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:BRASWELLS YUCAIPA LEISURE MANORFACILITY NUMBER:
360900100
ADMINISTRATOR:LINDA WOOFTERFACILITY TYPE:
740
ADDRESS:32195 AVENUE ETELEPHONE:
(909) 797-1314
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:61CENSUS: 43DATE:
05/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Linda Woofter Administrator TIME COMPLETED:
08:48 AM
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Licensing Program Analyst (LPA) Bernadette Allen amended the LIC9099-D on COMPLAINT CONTROL NUMBER: 56-AS-20230510083500 that was conducted on 5/15/2023. The typo's were corrected and signed by Linda Woofter.

An exit interview was conducted and this report was discussed and provided at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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