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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402583
Report Date: 10/25/2024
Date Signed: 10/25/2024 12:00:52 PM


Document Has Been Signed on 10/25/2024 12:00 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:BROOKDALE NORTH EUCLIDFACILITY NUMBER:
366402583
ADMINISTRATOR:LISA TOFACILITY TYPE:
740
ADDRESS:1031 N EUCLID AVETELEPHONE:
(909) 391-2622
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:140CENSUS: 63DATE:
10/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marcos RamosTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted a case management based on LPA observations during complaint#56-AS-20240612081444. LPA met with Business Office Manager (BOM), Marcos Ramos, and discussed the purpose of the visit.

LPA review of Staff #1 (S1) file reveals S1 is currently being shadowed and training started on October 2, 2024. BOM Ramos was advised to cover training regarding the facilities policy on discontinued medications and destruction.

A technical advisory on incidental and medical care was issued today. An exit interview was conducted where this report was discussed and a copy provided to BOM Ramos 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: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024
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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