<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412117
Report Date: 09/30/2024
Date Signed: 09/30/2024 10:34:45 AM

Document Has Been Signed on 09/30/2024 10:34 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:CAREGIVERS IIFACILITY NUMBER:
366412117
ADMINISTRATOR/
DIRECTOR:		JAEWON KIMFACILITY TYPE:
740
ADDRESS:10945 TRENMAR LANETELEPHONE:
(909) 877-0850
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 6CENSUS: 3DATE:
09/30/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jaewon Kim AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bernadette Allen met with Jaewon Kim Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 9/30/2024 at 10:15 AM to initiate a Case Management Office Visit.

LPA Allen requested that Jaewon Kim come into the office to sign an amended report to make corrections to deficiencies LIC809-D

An exit interview was conducted where this report was discussed, and a copy was provided to Jaewon Kim Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1