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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880720
Report Date: 02/09/2024
Date Signed: 02/09/2024 10:32:28 AM

Document Has Been Signed on 02/09/2024 10:32 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 4DATE:
02/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Rhea DavalosTIME COMPLETED:
10:35 AM
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Licensing Program Analysts (LPA) Paola Guerrero conducted an unannounced visit to the facility on 2/9/2024 at 9:11 AM for the purpose of a Health & Safety check. LPA Guerrero identified herself to Rhea Davalos and discussed the purpose of the visit. During the visit all four (4) clients were present . No imminent health and/or safety concerns observed at the time of visit. LPA Guerrero observed no health and/or safety hazards inside the facility. LPA Guerrero inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Guerrero observed sufficient staff present at the facility to provide care. LPA Guerrero inspected facility food supplies and observed three (3) day supply of perishable food supply and seven days (7) supply of non-perishable food supply. The needs of the clients in care appear to be met during this inspection.

An exit interview was conducted where this report (LIC809) was discussed and provided to Facility Licensee Rhea Davalos.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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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