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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530193
Report Date: 08/28/2024
Date Signed: 08/28/2024 09:41:29 AM

Document Has Been Signed on 08/28/2024 09:41 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:TIERRA RESIDENTIALFACILITY NUMBER:
365530193
ADMINISTRATOR/
DIRECTOR:		ROJAS, DIANAFACILITY TYPE:
735
ADDRESS:12445 TIERRA BONITA DRIVETELEPHONE:
(909) 455-8159
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 0DATE:
08/28/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Diana Rojas-LicenseeTIME VISIT/
INSPECTION COMPLETED:
09:48 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced follow up Prelicensing visit. This is an announced second Pre-Licensing visit conducted with Licensee, Diana Rojas who assisted in the tour of inside and outside of facility and the evaluation. The follow up visit was made to confirm that the corrections have been made.

The following have been corrected:
Enclosed fireplace made inaccessible to clients, required postings in a common area, fixed water heater with functioning stove and hot water measuring 107 degrees fahrenheit.

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.

Component III was completed. 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 Licensee, Diana Rojas.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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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