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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881306
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:09:35 AM

Document Has Been Signed on 07/21/2022 11:09 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:LUCKY J'S CARE HOME, INC.FACILITY NUMBER:
361881306
ADMINISTRATOR:RAVELO, CIELITA F.FACILITY TYPE:
735
ADDRESS:13192 ROLLING HILLS DRTELEPHONE:
(909) 569-2401
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 0DATE:
07/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Cielita Ravelo, Administrator
Jerry and Violeta Hermogino, Licensee		TIME COMPLETED:
11:20 AM
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Licensing Program Analysts (LPA) Rayshaun Nickolas conducted an announced visit to the facility for the purpose of verifying corrections from the initial Pre-Licensing inspection on July 11, 2022. At approximately 9:55 AM. LPA was greeted and granted entry by Licensee Violeta Hermogino . LPA observed the following:

Kitchen water temperature: The water temperature is 106.8.
Bathroom # 1 water temperature: The water temperature is 108.1.
LIC 610D Emergency and Disaster Plan: Posted at the facility.

LPA has determined that the facility is meeting operational requirements. LPA completed COMP III with Licensee and Administrator. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was emailed to the Licensee.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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