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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880602
Report Date: 09/25/2023
Date Signed: 09/25/2023 01:28:19 PM

Document Has Been Signed on 09/25/2023 01:28 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:IRIS STREETFACILITY NUMBER:
361880602
ADMINISTRATOR:PATRICIA ANN WOODSFACILITY TYPE:
735
ADDRESS:14733 IRIS STTELEPHONE:
(442) 249-1457
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
09/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Melissa King, Direct Support ProfessionalTIME COMPLETED:
01:28 PM
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On September 25, 2023 at 12:15 p.m., Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to investigate complaint control number 56-AS-20230706085846. LPA Nickolas met with Direct Support Professional Melissa King and explained the purpose of the visit.

LPA advised King that, at this time, the complaint requires further investigation. Possible follow-up telephone calls, requests for copies of relevant documents, and visits are necessary before reaching investigative findings.

No deficiencies were cited during this visit. An exit interview was conducted with King and a copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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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