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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411359
Report Date: 10/10/2024
Date Signed: 10/10/2024 02:29:19 PM

Document Has Been Signed on 10/10/2024 02:29 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GALA HOMEFACILITY NUMBER:
366411359
ADMINISTRATOR/
DIRECTOR:		TOLENTINO, LILIAN MA.FACILITY TYPE:
735
ADDRESS:10986 GALA LANETELEPHONE:
(909) 902-9108
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 6CENSUS: 6DATE:
10/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Facility Manager Jonathan SamonteTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 10/10/2024 Licensing Program Analysts (LPAs) Raquel Hernandez and Mary Rico conducted an unannounced case management visit based on the incident that occurred on 09/12/2024 pertaining to Client #1 (C1). LPAs were granted entrance to the facility and explained the purpose of today's visit to Facility Manager Jonathan Samonte. LPAs conducted a facility tour as well as obtained documentation pertaining to C1.

LPAs conducted (2) staff interviews and attempted to interview C1, however, C1 was unable to respond to LPAs. LPAs received copies of C1's discharge from hospital and orthopedic appointment. Also, LPAs received copy of staff phone numbers.

An exit interview was conducted, and a copy of this report was provided to Facility Manager Jonathan Samonte.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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