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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880818
Report Date: 02/04/2025
Date Signed: 02/04/2025 11:39:56 AM

Document Has Been Signed on 02/04/2025 11:39 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:DIVINE MANOR CARE INCFACILITY NUMBER:
361880818
ADMINISTRATOR/
DIRECTOR:		YADAV, SHREETAFACILITY TYPE:
740
ADDRESS:6367 MARBLE AVETELEPHONE:
(347) 449-2449
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 5DATE:
02/04/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Administrator Shreeta YadavTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 02/04/2025 Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to the facility to initiate a Case Management Health and Safety Check. LPA Hernandez was granted entry to the facility by staff Raymond Munsayac. LPA Hernandez met with Administrator Shreeta Yadav and explained the purpose of today's visit.

During today's visit LPA Raquel Hernandez toured the facility. All (5) residents were present at the facility during Health and Safety Check. No immediate health and safety concerns were observed. LPA Hernandez observed indoor and outdoor passageway and no health are safety hazards were observed. LPA Hernandez observed sufficient staff to provide proper care and supervision to residents in care. LPA Hernandez inspected food supply and observed more than two (2) days supply of perishable food and more than seven (7) days supply of non-perishable food.


Additionally, LPA Hernandez received documentation pertaining to incident reported.

An exit interview was conducted with Administrator Shreeta Yadav and a copy of this report (LIC809) was discussed and provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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