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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530014
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:34:57 PM

Document Has Been Signed on 11/29/2023 02:34 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:LONG MEADOW HOMEFACILITY NUMBER:
365530014
ADMINISTRATOR:CARR JR., MICHAELFACILITY TYPE:
735
ADDRESS:13170 LONG MEADOW ST.TELEPHONE:
(818) 309-7821
CITY:HESPERIASTATE: CAZIP CODE:
92344
CAPACITY: 4CENSUS: 4DATE:
11/29/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Erika Carr- LicenseeTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced collateral visit in relation to complaint control number: 56-AS-20230306164805. LPA met with Licensee, Erika Carr and explained the nature of the visit.

LPA conducted interviews with relevant parties. No deficiencies were observed during today's visit. A copy of this report was reviewed with and provided to Erika Carr at the conclusion of this visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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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