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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881045
Report Date: 03/24/2022
Date Signed: 03/24/2022 02:38:38 PM

Document Has Been Signed on 03/24/2022 02:38 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:SAHARIA CARE HOMES INC.FACILITY NUMBER:
361881045
ADMINISTRATOR:MATHUR, BHARTIFACILITY TYPE:
735
ADDRESS:7531 STONEY CREEK DRIVETELEPHONE:
(909) 856-9921
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 4DATE:
03/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Sachin Mathur - AdministratorTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted a case management visit to gather additional information in regards to the incident report received by the Department on 3/21/2022. The incident occurred on 3/18/2022. The visit is in response to the allegations made by C1 against the parent of C2 within the facility. This visit consisted of a review of the clients' files, observations of the facility, interviews with staff, as well as any health and safety issues. During today's visit, LPA was allowed entry and met with DSP S1 and explained the purpose of the visit. Administrator Sachin Mathur and S2 arrived shortly.

LPA reviewed C1 and C2 files and obtained copies including client Identification and Emergency Information sheet, DDS client profile, and IRC individual program plan.

At the time of this visit this home was found to be in compliance with regulatory requirements. It was determined that there were no health and safety issue observed in the facility at the time of this visit. No deficiencies were cited today in regard to this incident.

Administrator had to leave the facility prior to the conclusion of the visit. An exit interview was conducted and a copy of this report was given to S2.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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