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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881267
Report Date: 11/01/2023
Date Signed: 11/01/2023 01:54:39 PM

Document Has Been Signed on 11/01/2023 01:54 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:HANSEN RESIDENTIAL CAREFACILITY NUMBER:
361881267
ADMINISTRATOR:CLARKE, ZOIEFACILITY TYPE:
735
ADDRESS:374 S. VAN NESS AVE.TELEPHONE:
(909) 608-1699
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 4CENSUS: 0DATE:
11/01/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Zoie ClarkeTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA) Paola Guerrero conducted an unannounced visit to the facility on 11/1/2023 at 12:25 PM for the purpose of a Health & Safety check. LPA Guerrero identified herself to Zoie Clarke and discussed the purpose of the visit. At the time of the visit facility census was zero (0). No imminent health and/or safety concerns observed at the time of visit. LPA Guerrero observed no health and/or safety hazards inside the facility. LPA Guerrero inspected the outside perimeter of the facility LPA observed an in-ground pool in the backyard, the perimeter of pool is gated and locked LPA observed no health and/or safety hazards. Currently facility has no working staff. LPA Guerrero inspected facility food supplies and observed three (3) day supply of perishable and seven days (7) supply of non-perishable food.

An exit interview was conducted where this report (LIC809) was discussed and provided to Zoie Clarke.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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