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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427078
Report Date: 10/12/2022
Date Signed: 10/12/2022 03:21:16 PM

Document Has Been Signed on 10/12/2022 03:21 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:
10/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Sigmon Manalo, DSPTIME COMPLETED:
03:22 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for the purpose of delivering an amended report to complaint control number 56-AS-20220829161750

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

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: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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