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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881026
Report Date: 02/04/2021
Date Signed: 02/04/2021 11:02:20 AM

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:HESPERIA SENIOR CAREFACILITY NUMBER:
361881026
ADMINISTRATOR:WANG, JIN AFACILITY TYPE:
740
ADDRESS:17583 SULTANA STREETTELEPHONE:
(760) 440-7654
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:18CENSUS: 0DATE:
02/04/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jin A Wang, LicenseeTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Deborah Mullen conducted a tele-visit with Jin A Wang, Licensee to conduct a second pre-licensing inspection. Due to Covid 19 restrictions the visit was conducted via Microsoft Teams.

A second inspection was required to verify the corrections of items needed as identified during the initial pre-licensing inspection. The kitchen was observed to be fully stocked with plates, bowels, cups, silverware, serving bowls, pots and pans and cooking utensils. LPA observed the kitchen to be stocked with non-perishable foods. The dining room was furnished and able to seat 18 residents at one time. The living room area was observed to be furnished with a couch, recliners, side tables and other side chairs. LPA verified the posting of the Long Term Care Ombudsman poster, and games, puzzles and cards for residents use. The backyard was observed to be furnished with chairs and tables for residents use as well.

Based on todays inspection, the items identified during the initial pre-licensing were corrected and the facility is ready to be licensed.

An exit interview was conducted and a copy of this report was reviewed with Ms. Wang. The report was emailed to Ms. Wang for her review and signature.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
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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