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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880989
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:19:41 PM

Document Has Been Signed on 11/07/2023 12:19 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:PEOPLE'S CARE SYCAMOREFACILITY NUMBER:
361880989
ADMINISTRATOR:ZIA PICKENSFACILITY TYPE:
737
ADDRESS:17358 SYCAMORE LANETELEPHONE:
(760) 961-1014
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 4DATE:
11/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Zia PickensTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Mary Rico arrived at the facility unannounced to conduct a Case Management Visit for health and safety. This case management visit is in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 11/4/2023. LPA met with Administrator Zia Pickens.

During today's visit, LPA met with Administrator Zia Pickens in the office to discuss the incident and surrounding events. LPA did a health and safety check, and interviewed client and staff.

LPA received documents and informed Administrator that LPA will conduct additional interviews to determine findings.

An exit interview was conducted, and a copy of this report was provided to Administrator Zia Pickens.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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