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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880525
Report Date: 12/14/2022
Date Signed: 12/14/2022 10:30:08 AM


Document Has Been Signed on 12/14/2022 10:30 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:MERRILL GARDENS AT RANCHO CUCAMONGAFACILITY NUMBER:
361880525
ADMINISTRATOR:TAMO, DAVIDFACILITY TYPE:
740
ADDRESS:9942 HIGHLAND AVENUETELEPHONE:
(909) 303-9545
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY:150CENSUS: 113DATE:
12/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jeanane St. Louis -Business Office DirectorTIME COMPLETED:
10:45 AM
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On 5/20/2022 Licensing Program Analyst (LPA) Bernadette Allen was at the facility to initiate a complaint investigation CONTROL NUMBER 56-AS-20220518164927.

LPA Allen met with Jeanane St. Louis -Business Office Director she was informed that the LIC-9099-D was amended and needed to be signed. Jeanane informed me that David Tamo was not available but she could sign the required document.



No Deficiencies were cited at the time of visit.

An exit interview was conducted where this report was discussed and signed by Jeanane St.Louis a copy was 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: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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