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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880663
Report Date: 06/28/2023
Date Signed: 06/28/2023 03:07:49 PM

Document Has Been Signed on 06/28/2023 03:07 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:GRANT FAMILY HOMES INCFACILITY NUMBER:
361880663
ADMINISTRATOR:ROXANNE M GONZALESFACILITY TYPE:
735
ADDRESS:526 N ACACIA AVETELEPHONE:
(909) 440-5082
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 3DATE:
06/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Jimmie Grant, LicenseeTIME COMPLETED:
03:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Grant Family Homes, Adult Residential Facility to conduct a case management visit for the purposes of obtaining a signature on an amended report for complaint number 56-AS-20230301090201. LPA met with Licensee, Jimmie Grant introduced self and stated purpose of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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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