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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530131
Report Date: 09/25/2023
Date Signed: 09/25/2023 09:21:51 AM

Document Has Been Signed on 09/25/2023 09:21 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JACOB PROCARE HOME 1FACILITY NUMBER:
365530131
ADMINISTRATOR:SARROCA, ARVINFACILITY TYPE:
735
ADDRESS:13387 SUNNY RIDGE STTELEPHONE:
(626) 634-3919
CITY:HESPARIASTATE: CAZIP CODE:
92344
CAPACITY: 4CENSUS: 4DATE:
09/25/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Arvin Sarroca-AdministratorTIME COMPLETED:
09:24 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced follow up Prelicensing visit on 09/25/2023. This is an announced second Pre-Licensing visit conducted with Licensee, Arvin Sarroca who assisted in the tour of inside and outside of facility and the evaluation. The follow up visit was made to confirm that the correction has been made.

A new application for capacity of 4 ambulatory clients, updated facility sketch and approved fire inspection clearance for 4 ambulatory clients.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. LPA completed COMP III with the Administrator at the conclusion of the inspection.

Licensee will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided with Administrator, Arvin Sarroca.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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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