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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880526
Report Date: 07/26/2024
Date Signed: 07/26/2024 01:10:48 PM

Document Has Been Signed on 07/26/2024 01:10 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DEMOH ADULT HOME IFACILITY NUMBER:
361880526
ADMINISTRATOR/
DIRECTOR:		PATRICK, MICHAELFACILITY TYPE:
735
ADDRESS:13700 CYPRESS AVETELEPHONE:
(760) 596-4994
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 4DATE:
07/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Crystal Pedraza-StaffTIME VISIT/
INSPECTION COMPLETED:
01:14 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to amend findings for 56-AS-20231221161104. LPA introduced self and stated the purpose of the visit to Staff, Crystal Pedraza.

During today's visit, LPA amended the report and discussed the updated findings.

No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to Staff, Crystal Pedraza.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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