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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426867
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:15:25 PM

Document Has Been Signed on 04/13/2022 03:15 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:HACIENDA CAREFACILITY NUMBER:
366426867
ADMINISTRATOR:LAYGO, ANITAFACILITY TYPE:
735
ADDRESS:13874 CHOCO RDTELEPHONE:
(760) 946-2033
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 5DATE:
04/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:52 PM
MET WITH:Jason Laygo ManagerTIME COMPLETED:
03:20 PM
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This is an amended report that replaces the original report dated 3/2/2022

Licensing Program Analyst (LPA) Bernadette Allen an unannounced case management visit to this facility to obtain signature to amended report dated 3/2/2022. This report was discussed and a copy was provided to Jason Laygo Manager at the time of visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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