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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409910
Report Date: 07/27/2022
Date Signed: 07/27/2022 11:52:46 AM

Document Has Been Signed on 07/27/2022 11:52 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:VENTANA ARF-MONTE VERDEFACILITY NUMBER:
366409910
ADMINISTRATOR:HECTOR OBARFACILITY TYPE:
735
ADDRESS:1196 MONTE VERDE AVETELEPHONE:
(909) 985-7390
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 2DATE:
07/27/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Grace Obar, AdministratorTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit at the facility for the purpose of conducted a Plan of Correction (POC) visit. LPA met with administrator Grace Obar who was informed of the purpose of the visit.

On 6/21/2022 the facility was issued two deficiencies with a plan of correction date of 7/1/2022. LPA verified that the facility licensing fee has been paid. The facility will receive a Letter of Deficiency Citation Cleared for this deficiency. Administrator Obar requested a POC extension date for the locked staff room. LPA Bueno granted an extension date of 8/7/2022.

An exit interview was conducted where a copy of this report was discussed with and provided to Ms. Obar.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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