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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800433
Report Date: 11/30/2022
Date Signed: 11/30/2022 03:19:38 PM

Document Has Been Signed on 11/30/2022 03:19 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:WELLSPRING CENTERFACILITY NUMBER:
361800433
ADMINISTRATOR:LAWRENCE LAWLERFACILITY TYPE:
772
ADDRESS:15217 SAN BERNARDINO AVENUETELEPHONE:
(951) 643-2150
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 16CENSUS: 14DATE:
11/30/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Holly Still, LCSWTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility. LPA Prieto met with Holly Still and explained the reason for the visit.

The Health and Safety check included overall observation of the facility inside, and outside, including food supply, medications, physical plant, and obtained client documentation. LPA Prieto did not observe any safety hazards.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to MS Still

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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