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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427078
Report Date: 10/10/2022
Date Signed: 10/10/2022 02:49:26 PM

Document Has Been Signed on 10/10/2022 02:49 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: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:
10/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Sigmond Manalo, DSPTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for the purpose of delivering findings to complain control number 56-AS-20220829161750 and to verify that the walled area attached to the home is not being utilized as a sleeping area.

Findings for complain control number 56-AS-20220829161750 is unsubstantiated. Refer to LIC 9099 for details on this complaint.

On 9/2/2022, LPA Bueno observed a walled area attached to the right side of the home, next to the great room kitchen and dining area. The room has two windows and is accessed through a door. During today’s visit, LPA Bueno inspected the room and did not observe a bed or any seating that can be used as a frame of a bed inside this area.

No deficiencies were citied during today’s visit. An exit interview was conducted where this report was discussed with, and a copy was provided to Mr. Manalo at the conclusion of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
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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