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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427080
Report Date: 03/30/2021
Date Signed: 03/30/2021 10:19:32 AM

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
RIVERSIDE, CA 92507
FACILITY NAME:GENTLE CARE GUEST HOMEFACILITY NUMBER:
366427080
ADMINISTRATOR:KAOCHAROEN,SUWANNEEFACILITY TYPE:
740
ADDRESS:11513 ACACIA ST.TELEPHONE:
(909) 796-5508
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:9CENSUS: 0DATE:
03/30/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Suwannee Kaocharoen, LicenseeTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA), Deborah Mullen, conducted a tele-visit inspection of the home with Licensee, Suwannee Kaocharoen. The purpose of the inspection was to verify the relocation of residents due to the closure of the facility. LPA was able to verify the relocation of all residents. Licensee was advised that the licensee would be closed effective today, March 30, 2021.

An exit interview was conducted where this report was reviewed with Licensee. LPA emailed report to licensee for her review and signature.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
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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