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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427078
Report Date: 09/15/2022
Date Signed: 09/15/2022 09:21:58 AM

Document Has Been Signed on 09/15/2022 09:21 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:HOLLY LAND CARE HOMEFACILITY NUMBER:
366427078
ADMINISTRATOR:PENDINGFACILITY TYPE:
735
ADDRESS:2044 HOLLY AVENUETELEPHONE:
(909) 972-8497
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 6CENSUS: 4DATE:
09/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:James Santiago, AdministratorTIME COMPLETED:
09:23 AM
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Licensing Program Analyst (LPA) Anna Bueno an unannounced visit to the facility for a case management relative to observation of the physical plant that LPA observed during a visit on 9/2/2022. LPA met with Administrator James Santiago who was informed of the nature of the visit.

On 9/2/2022, LPA Bueno observed a walled area next to the outside of the home. The area can be accessed through a door from the roofed outdoor area. The walled area has a window and shares a wall with the home. From the door, LPA Bueno observed the following furniture and appliance flushed against the right wall: a bed and a low table with a television on it. LPA observed that the left wall was lined with hanged clothing items.

During tody's visit, LPA viewed the area again and advised administrator Santiago to remove the futon inside the walled area. LPA Bueno advised Mr. Santiago that the area cannot be used for sleeping until the local Fire Department has cleared the area as a bedroom. Two technical assistance were issued during today's visit.

An exit interview was conducted where this report and LIC9102TA were reviewed and copies were provided to Administrator Santiago.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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