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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530095
Report Date: 06/20/2023
Date Signed: 06/20/2023 10:58:41 AM

Document Has Been Signed on 06/20/2023 10:58 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:DIVINE MANOR CARE 2FACILITY NUMBER:
365530095
ADMINISTRATOR:YADAV, SHREETAFACILITY TYPE:
740
ADDRESS:544 W 9TH STREETTELEPHONE:
(347) 449-2449
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 5DATE:
06/20/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Administrator/Applicant Shreeta YadavTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Melody Brown conducted an announced Prelicensing visit 06/20/2023 at 09:53 AM. This is an announced Pre-Licensing visit conducted with Applicant/Administrator Shreeta Yadav who assisted in the tour of inside and outside of facility and the evaluation. LPA Melody Brown made a second (2nd) announced Prelicensing visit this date. The follow up visit was made to confirm that all corrections have been made.

Obtain/Purchase 72-hour emergency food supply for residents, Obtain/Purchase 72-hour emergency bag pack for residents, Staff Medication Training with Staff Training Log (medications need to be in a locked drawer), Purchase Closet for Resident #1 (R1) and Resident #5 (R5), Post Rights of Resident Council Board, Post Family Council Board - All were found to be corrected on this visit date, 06/20/2023.

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.



Applicant/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 Applicant/Administrator Shreeta Yadav.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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