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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530183
Report Date: 04/17/2024
Date Signed: 04/17/2024 12:53:01 PM

Document Has Been Signed on 04/17/2024 12:53 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
, CA 95814
FACILITY NAME:GEORGETTE ADULT RESIDENTIALFACILITY NUMBER:
365530183
ADMINISTRATOR/
DIRECTOR:		GARCIA, JEANETTEFACILITY TYPE:
735
ADDRESS:5057 AGAVE AVETELEPHONE:
(909) 641-1108
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 2CENSUS: 0DATE:
04/17/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Jeanette Garcia, Administrator/Applicant
George Garcia, Applicant		TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 2
Census (if any clients in care): none
COMP II Participants: Jeanette Garcia, Administrator/Applicant
George Garcia, Applicant
Interview Method: Telephone interview

On April 17, 2024 at 11:00 AM, Applicants and Administrator participated in COMP II. Identification of the Applicants and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicants and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB analyst confirmed Applicants and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicants and Administrator. Copy of report sent via email and informed to send sign copy to CAB by end of business day today.
SUPERVISORS NAME: Joshua Miller
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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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