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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530053
Report Date: 01/26/2024
Date Signed: 01/26/2024 12:52:04 PM

Document Has Been Signed on 01/26/2024 12:52 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:KINDER DILIGENCE CARE, INCFACILITY NUMBER:
365530053
ADMINISTRATOR:GREEN, D'JARNETTEFACILITY TYPE:
735
ADDRESS:16492 KASOTA ROADTELEPHONE:
(760) 810-7036
CITY:APPLEY VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 2CENSUS: 2DATE:
01/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Licensee Kenisha Polk TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Mary Rico conducted an announced visit to the facility for the purpose of increasing the capacity. LPA was greeted and granted entrance by the Licensee Kenisha Polk.

Per the LIC200, Licensee requested for the change of capacity from (0) non-ambulatory to (2) non-ambulatory. For ambulatory it remained the same for two (2) ambulatory clients. The fire clearance request was approved on 1/12/2024 for (2) non-ambulatory and (2) ambulatory clients.

The licensee was advised that the noted designated capacity for each room is to remain in compliance.

LPA observed that the client bedrooms were appropriately furnished and had functional lighting. The physical plant is ready for an increase in capacity. LPA will update the facility's file and issue a new license stating change in capacity.

An exit interview was conducted where this report LIC809 was discussed and provided to the Licensee Kenisha Polk .

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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