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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427383
Report Date: 09/16/2021
Date Signed: 09/16/2021 12:18:22 PM

Document Has Been Signed on 09/16/2021 12:18 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
RIVERSIDE, CA 92507
FACILITY NAME:ESPINOZA ADULT CARE HOME IFACILITY NUMBER:
366427383
ADMINISTRATOR:LYDIA ESCUTIAFACILITY TYPE:
735
ADDRESS:14232 SAVANA STREETTELEPHONE:
(909) 770-3544
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 5CENSUS: 4DATE:
09/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Candice Dubief - Assistant AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility and met with Assistant Administrator Candice Dubief in order to deliver findings and obtain signatures for an amended complaint report (#18-AS-20191108100012) for sister facility (361800205). LPA Colvin went over the amended report with Assistant Administrator Candice and provided a copy of the amended complaint report.

LPA Colvin conducted an exit interview with Assistant Administrator Candice Dubeif and a copy of this report was provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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