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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401304
Report Date: 06/03/2022
Date Signed: 06/03/2022 10:37:30 AM


Document Has Been Signed on 06/03/2022 10:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:MARIA VICTORIA'S HOME CARE -AFACILITY NUMBER:
366401304
ADMINISTRATOR:CACHAPERO, HENRYFACILITY TYPE:
740
ADDRESS:11523 PEMBROKE STREETTELEPHONE:
(909) 799-1537
CITY:LOMA LINDASTATE: CAZIP CODE:
92350
CAPACITY:6CENSUS: 4DATE:
06/03/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Henry CachaperoTIME COMPLETED:
10:46 AM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility. LPA Gardner met with Henry Cachapero and explained the reason for the visit.

The Health and Safety check included overall observation of the facility inside, and outside, including food supply, medications, physical plant, and the clients in care. LPA Gardner did not observe any safety hazards.

During today’s visit, LPA Gardner interviewed Staff (S1) and received documents regarding complaint number 18-AS-20220218081830.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Henry Cachapero.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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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