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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800165
Report Date: 12/28/2022
Date Signed: 12/29/2022 02:14:54 PM

Document Has Been Signed on 12/29/2022 02:14 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:AUSTIN SMALL ARIZONA FAMILY HOME IIFACILITY NUMBER:
361800165
ADMINISTRATOR:AUSTIN, ALEXANDRIAFACILITY TYPE:
735
ADDRESS:17049 LA VESU ROADTELEPHONE:
(909) 823-2624
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 3DATE:
12/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Sabrina Weddles TIME COMPLETED:
02:16 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to deliver an amended report of complaint control number: 56-AS-20221207132122. LPA met with Sabrina Weddles.

Findings for complaint control number 56-AS-20221207132122 remains unchanged:
The allegation Resident was given alcohol against conservator consent not to is UNSUBSTANTIATED.

Ms. Sabrina Weddles signed the amended LIC9099. The report was discussed with and copies were provided to facility representative at the conclusion of today’s visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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