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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426473
Report Date: 01/04/2023
Date Signed: 01/04/2023 11:05:08 AM

Document Has Been Signed on 01/04/2023 11:05 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:KENNETH ADULT RESIDENTIAL IVFACILITY NUMBER:
366426473
ADMINISTRATOR:CHAVEZ, JAMES EFACILITY TYPE:
735
ADDRESS:4068 MIRA MESA AVE.TELEPHONE:
(909) 464-8116
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: 4DATE:
01/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sylvia CahvezTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to have administrator Sylvia Chavez sign amended Facility Evaluation Report (LIC 809) related to an Annual 1 year required visit that was conducted on 08/29/2022. LPA Prieto and Administrator Chavez signed LIC 809, dated 08/29/2022, and this document and copies were left at the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2023
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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