Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330909315
Report Date: 09/12/2017
Date Signed: 09/12/2017 03:43:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:V.I.P. TOTSFACILITY NUMBER:
330909315
ADMINISTRATOR:MARCELLA ARNOLDFACILITY TYPE:
850
ADDRESS:41861 E. ACACIA AVENUETELEPHONE:
(951) 652-7611
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:86CENSUS: 27DATE:
09/12/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Marcella ArnoldTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Laura Callahan met with Assistant Executive Director Marcella Arnold and discussed the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 09/06/17. Ms. Arnold stated that a prior visit was conducted by LPA Sharleen Robinson on 09/07/17 in regards to the reported incident.

LPA observed that LPA Robinson addressed the reported incident and issued a report. Per LPA Robinson, no further action is needed at this time.

An exit interview was conducted and a copy of this report was provided to the facility at time of visit.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Laura CallahanTELEPHONE: (951) 204-4913
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2017
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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