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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881026
Report Date: 02/01/2023
Date Signed: 02/01/2023 10:49:09 AM


Document Has Been Signed on 02/01/2023 10:49 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:HESPERIA SENIOR CAREFACILITY NUMBER:
361881026
ADMINISTRATOR:WANG, JIN AFACILITY TYPE:
740
ADDRESS:17583 SULTANA STREETTELEPHONE:
(760) 669-0109
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:18CENSUS: 10DATE:
02/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Jin A. Wang, Licensee/AdministratorTIME COMPLETED:
10:53 AM
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On 02/1/2023, at 10:18 a.m., Licensing Program Analysts (LPA) Rayshaun Nickolas made an unannounced visit to the facility to obtain signatures on amended LIC 9099s. LPA met with Licensee/Administrator Jin A. Wang and explained the purpose of the visit.

An exit interview was conducted and a copy of this report and amended LIC 9099s were provided to Wang.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
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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