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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800118
Report Date: 09/19/2024
Date Signed: 09/19/2024 01:07:08 PM


Document Has Been Signed on 09/19/2024 01:07 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ANGELIC MANSIONSFACILITY NUMBER:
361800118
ADMINISTRATOR:RAJADAS, STEVEN PFACILITY TYPE:
740
ADDRESS:7585 WARREN VISTA AVETELEPHONE:
(760) 365-4620
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:15CENSUS: 15DATE:
09/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Administrator Steven Rajadas TIME COMPLETED:
01:15 PM
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On 9/19/2024 Licensing Program Analyst Sarina Ramirez arrived at the facility to amend documents originally delivered on 07/31/24

On 07/31/2024 LPA Ramirez was at the facility to initiate a complaint investigation COMPLAINT CONTROL NUMBER: 56-AS-20240726112144

The amendment was signed by Administrator Rajada and he was provided a copy of the amended report at the conclusion of the visit

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina RamirezTELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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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