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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426418
Report Date: 05/24/2023
Date Signed: 05/24/2023 10:12:44 AM

Document Has Been Signed on 05/24/2023 10:12 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:M&M BOARD & CAREFACILITY NUMBER:
366426418
ADMINISTRATOR:MERCADO, VICTORFACILITY TYPE:
740
ADDRESS:18245 CHERRY ST.TELEPHONE:
(760) 488-1698
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 8CENSUS: 3DATE:
05/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Victor Mercado, Licensee/AdministratorTIME COMPLETED:
10:17 AM
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On 05/24/2023 at 09:59 a.m., Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to obtain signatures on amended LIC 9099. LPA met with Licensee/Administrator Victor Mercado and explained the purpose of the visit.

An exit interview was conducted and a copy of this report and amended LIC 9099 were provided to Mercado
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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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