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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881267
Report Date: 11/30/2021
Date Signed: 11/30/2021 10:20:18 AM

Document Has Been Signed on 11/30/2021 10:20 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
RIVERSIDE, CA 92507
FACILITY NAME:HANSEN RESIDENTIAL CAREFACILITY NUMBER:
361881267
ADMINISTRATOR:CLARKE, ZOIEFACILITY TYPE:
735
ADDRESS:374 S. VAN NESS AVE.TELEPHONE:
(310) 490-9069
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 4; 4CENSUS: 0DATE:
11/30/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Zoie ClarkTIME COMPLETED:
10:30 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) Javier Prieto arrived to the facility for an announced pre licensing inspection. LPA Prieto met with administrator Clark and toured facility. During time of inspection, the home was not prepared a pre licensing inspection physically and no facility documentation was present. LPA Prieto stated to Ms Clark that once the home is clean, cleared of debris, water pressure and temperature are adjusted, as well as the home being fully furnished, Clark may phone LPA to arrange to a pre licensing inspection. LPA Prieto informed Ms Clark that a COMP III inspection will be conducted during second visit. This report was signed by both Ms Clark and LPA Prieto and a copy was left at the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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