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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530222
Report Date: 07/17/2024
Date Signed: 07/17/2024 11:12:52 AM

Document Has Been Signed on 07/17/2024 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SU CASAFACILITY NUMBER:
335530222
ADMINISTRATOR/
DIRECTOR:		VILLEGAS, ESMERALDAFACILITY TYPE:
740
ADDRESS:6221 ROUNER DRTELEPHONE:
(951) 833-3310
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY: 6CENSUS: 0DATE:
07/17/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Esmeralda VillegasTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) Javier Prieto and Sarina Ramirez conducted an announced Pre licensing visit 07/17/2024 at 09:00 AM. This is an announced Pre-Licensing visit conducted with Administrator Esmeralda Villegas who assisted in the tour of inside and outside of facility and the evaluation. The follow up visit was made and observed the following.

The facility is a three (3) bedroom and two (2) bathroom home with an attached garage. Facility tour reveals the physical plan meeting regulations. Water temperature measured 112 degrees. Facility has appropriate furnishings to meet the needs of the residents. Outdoor tour is free from obstructions. The facility has locked cabinets where medication, disinfectants, and other items that are to be inaccessible to clients are needed. The facility carbon monoxide and smoke detectors were tested and found to be in working order. On this date, a COMP III orientation was conducted.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, CCR. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure.

Administrator will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided with Administrator Esmeralda Villegas
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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