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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410632
Report Date: 08/14/2023
Date Signed: 08/14/2023 01:55:30 PM

Document Has Been Signed on 08/14/2023 01:55 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:KHEESA'S FAMILY HOMEFACILITY NUMBER:
366410632
ADMINISTRATOR:THOMAS, D'ANN TFACILITY TYPE:
735
ADDRESS:17269 SAN BERNARDINO AVE.TELEPHONE:
(909) 427-0957
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 4DATE:
08/14/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Laporsha GrantTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. LPA arrived at the facility to conduct a Case Management- Health and Safety Check on 8/14/2023 at 1:10 PM. LPA identified herself to Laporsha Grant and discussed the purpose of the visit. At the time of the visit LPA observed that all clients in care were present. No imminent health and/or safety concerns were observed during the time of the visit. All clients appeared to be okay no visual injuries were observed. LPA conducted a walk through of the facility LPA observed no health and/or safety hazards inside the facility. LPA Guerrero inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Guerrero observed sufficient staff present at the facility to provide care. LPA inspected facility food supplies and observed three (3) day supply of perishable and seven days (7) supply of non-perishable food. The needs of the clients in care appear to be met during this inspection.

An exit interview was conducted where this report (LIC809) was discussed and provided to Laporsha Grant.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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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