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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401304
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:21:54 PM


Document Has Been Signed on 05/26/2023 03:21 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: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: 3DATE:
05/26/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Henry & Melita CachaperoTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility. LPA Malcore met with Henry Cachapero and explained the reason for the visit.

LPA arrived at the facility and observed 3 residents in care. Cachapero stated that there are no residents on hospice or bedridden.

During today's visit, LPA observed two (2) residents in the dining room area, and one (1) resident in a private bedroom.

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

Based on the observations made during today’s visit, no deficiencies cited at this time.

An exit interview was conducted where this report (LIC 809) was discussed and a copy of this report was provided Cachapero at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
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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