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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881040
Report Date: 03/14/2023
Date Signed: 03/14/2023 01:23:39 PM


Document Has Been Signed on 03/14/2023 01:23 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:GRACIOUS LIVINGFACILITY NUMBER:
361881040
ADMINISTRATOR:KAO, ANGELFACILITY TYPE:
740
ADDRESS:312 W ASTER ST.TELEPHONE:
(626) 622-0671
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 0DATE:
03/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Leofel CapulongTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Paola Guerrero conducted an announced visit to conduct a final walk-through purpose of facility closure. LPA arrived and met with Facility Manager Leofel, LPA, Guerrero conducted a walkthrough of the facility both inside and outside. LPA, Guerrero verified that there were no residents present, and there were no belongings of residents in the facility. LPA Guerrero was informed all residents have been relocated and facility has been closed since 02/14/2023. LPA inspected the entire facility which included the bedrooms, bathrooms, dining area, kitchen, and the backyard. Home will be used as a private residence . Administrator stated reason for closure is due to lease not being renewed by the property home owner.

LPA, Guerrero requested license from the licensee, and Jesse stated stated that the document will be mailed to CCL Office.

The effective date of closure will be 3/14/2023

An exit interview was conducted, and a copy of this report was discussed and provided to Facility Manager Leofel Capulong
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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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