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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401304
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:02:03 AM


Document Has Been Signed on 03/10/2022 10:02 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:
03/10/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Henry CachaperoTIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Javier Prieto conducted a Case Management. LPA conducted an inspection of facility premises and observed and spoke with residents in care.

Food supply and resident medications were inspected. LPA met with Henry Cachapero.

At this time, no deficiencies are issued. No immediate health and safety concerns noted.

A copy of this report will be provided to the Administrator.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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