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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880863
Report Date: 12/13/2021
Date Signed: 12/13/2021 12:25:31 PM

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
RIVERSIDE, CA 92507
FACILITY NAME:ALOHA RESIDENTIAL CAREFACILITY NUMBER:
361880863
ADMINISTRATOR:KHAN, ASMATFACILITY TYPE:
740
ADDRESS:7476 BUNGALOW WAYTELEPHONE:
(951) 675-7763
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91739
CAPACITY:6CENSUS: 4DATE:
12/13/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Asmat Khan, licenseeTIME COMPLETED:
11:10 AM
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On 12/13/21, Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of conducting a health and wellness check on the residents in care. The LPA initially met with caregivers Dorenda Cruz and Ramonsito Cruz. Licensee Asmat Khan arrived to the facility shortly after. During today's visit, there were 4 resident's in care. Resident 1, Resident 2, Resident 3 and Resident 4 were present during the visit. There were no health and safety concerns observed during the visit.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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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