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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424401
Report Date: 10/10/2022
Date Signed: 10/10/2022 12:28:44 PM

Document Has Been Signed on 10/10/2022 12:28 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:LMB CARE HOMEFACILITY NUMBER:
366424401
ADMINISTRATOR:BRANDON DELGADOFACILITY TYPE:
735
ADDRESS:1316 N. SAN ANTONIO AVENUETELEPHONE:
(909) 204-2722
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 3DATE:
10/10/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Estela MolinaTIME COMPLETED:
12:38 PM
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Licensing Program Analysts (LPAs) Natalie Ibarra and Victoria Chitgain conducted an unannounced case management visit to the facility for a Health & Safety Check. LPAs met with Direct Support Professional (DSP) Estela Molina. The Administrator Marilyn Delgado was contacted regarding visit.

LPAs observed the facility to have the required amount of food, utilities are operational, medication for all clients present, and personal hygiene supplies. LPAs briefly interviewed client that was currently present at the facility. Client stated that they are well fed and have their needs met. LPAs did not observe any Health and Safety concerns at this time.

An exit interview was conducted, and report was discussed and provided to DSP Estela Molina
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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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