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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700091
Report Date: 10/17/2022
Date Signed: 10/17/2022 02:47:03 PM

Document Has Been Signed on 10/17/2022 02:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:CALVARY SENIOR CARE LLCFACILITY NUMBER:
364700091
ADMINISTRATOR:BOSOMPEM, ANDREWFACILITY TYPE:
300
ADDRESS:9650 BUSINESS CENTER DR, # 110TELEPHONE:
(909) 317-4749
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: CENSUS: DATE:
10/17/2022
Required - 2 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Andrew BosompemTIME COMPLETED:
02:45 PM
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Calvary Senior Care on 10/17/2022. Upon arrival, the HCSB analyst identified himself and was greeted by Andrew Bosompem. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with Andrew and informed the licensee that no discrepancies were found. In addition, the licensee was provided a printed copy of the LIC 9058 (Applicant/Licensee Rights) form.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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