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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880596
Report Date: 09/28/2022
Date Signed: 10/06/2022 09:39:26 AM

Document Has Been Signed on 10/06/2022 09:39 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:CAROLINE STREETFACILITY NUMBER:
361880596
ADMINISTRATOR:PATRICIA WOODSFACILITY TYPE:
735
ADDRESS:14461 CAROLINE STTELEPHONE:
(442) 249-1310
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
09/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Patricia Woods-AdministratorTIME COMPLETED:
11:30 AM
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*The is an amended document originally delivered on 9/28/2022*

On 9/28/2022 Licensing Program Analyst (LPA) Bernadette Allen was at the facility to initiate a complaint investigation Complaint #56-AS-20220927151703

A Health and Safety check was done and LPA Allen observed the facility inside and outside, food supply, physical plant, and the clients in care. LPA observed the facility to be controlled by the air conditioner. LPA observed shaded sitting areas outside for the residents/ staff and visitors. The facility has the required amount of food and water supply for the residents in care. LPA, Allen observed charged fire extinguishers and carbon monoxide detectors. All bedrooms have sufficient lighting and furniture. The restrooms had running water and required hygiene Items.

The four (4) residents in care were observed and there were no health and safety concerns at the time of visit.

An exit interview was conducted where this report was discussed and a copy of the report was provided to Patricia Woods-Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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