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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881272
Report Date: 04/12/2022
Date Signed: 04/12/2022 02:26:36 PM

Document Has Been Signed on 04/12/2022 02:26 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, 744 P STREET, MS 9-14-8201
, CA 95814
FACILITY NAME:ST. CLARE FAMILY HOMEFACILITY NUMBER:
361881272
ADMINISTRATOR:TAN, CARLITOFACILITY TYPE:
735
ADDRESS:2608 GARFIELD AVENUETELEPHONE:
(909) 472-1767
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 4CENSUS: DATE:
04/12/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Antonio Sanchez, Carlito Tan TIME COMPLETED:
02:25 PM
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Component II completion: Successful

Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: Antonio Sanchez, Carlito Tan
Interview Method: Telephone

On 4/12/22, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Tracy Thompson
LICENSING EVALUATOR NAME: Susan Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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