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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880720
Report Date: 10/17/2022
Date Signed: 10/17/2022 04:50:46 PM

Document Has Been Signed on 10/17/2022 04:50 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:SHAMROCK CARE HOMEFACILITY NUMBER:
361880720
ADMINISTRATOR:ROMEL C CAPALARANFACILITY TYPE:
735
ADDRESS:1741 ERIN AVETELEPHONE:
(909) 697-9843
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY: 6CENSUS: 3DATE:
10/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:36 PM
MET WITH:Almario Quizon, DSPTIME COMPLETED:
04:52 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for the purpose of delivering findings to complaint control number: 56-AS-20220317155642. Refer to LIC 9099 for details on this complaint.

Licensee phoned the facility and spoke with LPA regarding a pending submission of a waiver for locked kitchen cabinets. During today's visit, LPA did not observe kitchen cabinets to be locked however the spice cabinet is.

No deficiencies were cited during today’s visit. An exit interview was conducted where this report was discussed with, and a copy was provided to Mr. Quizon at the conclusion of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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