<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881048
Report Date: 04/27/2022
Date Signed: 04/27/2022 11:26:25 AM


Document Has Been Signed on 04/27/2022 11:26 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:AQUA RIDGE OF MONTCLAIRFACILITY NUMBER:
361881048
ADMINISTRATOR:MONIQUE DEL JUNCOFACILITY TYPE:
740
ADDRESS:9631 MONTE VISTA AVETELEPHONE:
(909) 483-2782
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:115CENSUS: 18DATE:
04/27/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Deborah Main, Community Relations DirectorTIME COMPLETED:
11:27 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for the purpose of completing a Health & Safety check. Upon arrival LPA's met with Debora Main, Community Relations Director, and explained the nature of the visit. LPA was granted entry into the facility.

During today's visit, LPA toured the facility with Ms. Main. LPA and observed memory care resident eating breakfast in the dining room and other memory care residents in the sitting area watching the television. No imminent health/safety concerns were observed. Residents in care appeared to be safe with no imminent health and safety concerns. The facility was maintained at a comfortable temperature for the residents in care. The needs of the residents in care appeared to be met during the LPA's inspection.

An exit interview was conducted where this report was discussed and provided to the Melissa Sumling, Resident Service Director.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1