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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880928
Report Date: 05/18/2022
Date Signed: 05/18/2022 02:48:30 PM

Document Has Been Signed on 05/18/2022 02:48 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:MAE WEST HOME CARE LLCFACILITY NUMBER:
361880928
ADMINISTRATOR:RFACILITY TYPE:
735
ADDRESS:35544 MT. VIEW STREETTELEPHONE:
(909) 570-4758
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 3CENSUS: 0DATE:
05/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Administrator-La Nette AdamsTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for the purpose of increasing the capacity, per the licensee/administrator request. LPA met with Administrator La Nett Adams.

Per the LIC200, the administrator requested for the capacity increase from three (3) to four (4) on 9/10/2021. The fire clearance request was approved on 4/11/2022 for four (4) ambulatory clients.

There is a facility sketch on file with designation of capacity for each room. The administrator was advised that the noted designated capacity for each room is to remain in compliance.

LPA observed that the client bedrooms were appropriately furnished and had functional lighting. The physical plant is ready for an increase in capacity. LPA will update the facility's file and issue a new license stating change in capacity.

There are currently have zero (0) clients in care.

An exit interview was conducted where this report was discussed and provided to the licensee.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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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