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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426087
Report Date: 11/20/2023
Date Signed: 11/20/2023 03:06:25 PM

Document Has Been Signed on 11/20/2023 03:06 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A & K PRIVATE HOME CAREFACILITY NUMBER:
366426087
ADMINISTRATOR:VOODTIKON PHUMIRATFACILITY TYPE:
740
ADDRESS:11490 POPLAR STREETTELEPHONE:
(909) 478-1482
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 6CENSUS: 6DATE:
11/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Anchalee Phumirat, LicenseeTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted and unannounced case management visit to the facility. LPA Malcore met with Licensee, Anchalee Phumirat and discussed the purpose of the visit.

LPA Malcore amended a Licensing report which was issued during a visit conducted on 8/11/23.

No deficiencies were cited during today's visit. An exit interview was conducted with the Licensee and a copy this report and amended report was provided to the Licensee at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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