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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401304
Report Date: 07/21/2023
Date Signed: 07/21/2023 10:16:27 AM


Document Has Been Signed on 07/21/2023 10:16 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: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:
07/21/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Henry CachaperoTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to conduct a Health and Safety check at the facility. LPA met with Henry Cachapero and explained the reason for the visit. The facility has a current census of three (3) with no residents on hospice or bedridden.

The Health and Safety check included overall observation of the facility inside and outside, including food supply, medications, physical plant, telephone service and residents in care. LPA observed resident #1 (R1) and resident #2 (R2) in the dining room. LPA observed resident #3 (R3) was in their bedroom.

No health and safety concerns were observed during today's visit. No deficiencies were cited.

An exit interview was conducted where this report was discussed and a copy of this report was provided Henry 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: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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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