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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426087
Report Date: 04/27/2022
Date Signed: 04/27/2022 09:48:23 AM


Document Has Been Signed on 04/27/2022 09:48 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:A & K PRIVATE HOME CAREFACILITY NUMBER:
366426087
ADMINISTRATOR:VOODTIKON PHUMIRATFACILITY TYPE:
740
ADDRESS:11490 POPLAR STREETTELEPHONE:
(909) 478-1482
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 6DATE:
04/27/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Voodtikon PhumiratTIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 04/27/2022 at 08:45 AM, unannounced for a collateral visit on a complaint investigation to interview Resident #1 (R1). During this visit LPA Brown was met by facility Administrator Voodtikon Phumirat. Administrator Phumirat assisted the interviewing process. LPA was able to meet with R1 during this visit.

An exit interview was conducted and a copy of this report (LIC809) was discussed and provided to the Administrator Voodtikon Phumirat .
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
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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