<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501069
Report Date: 11/18/2021
Date Signed: 11/18/2021 09:52:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:SAN MARINO COMMUNITY CHURCHFACILITY NUMBER:
191501069
ADMINISTRATOR:JIHAN MOUSSAUDFACILITY TYPE:
850
ADDRESS:1750 VIRGINIA RDTELEPHONE:
(626) 282-4186
CITY:SAN MARINOSTATE: CAZIP CODE:
91108
CAPACITY:75CENSUS: 43DATE:
11/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jihan Massoud - DirectorTIME COMPLETED:
09:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced Case Management-Other inspection in order to deliver an Amended Report and obtain the signature of Director Jihan Massoud on four of five pages of a report. Upon Arrival at 9am, LPA was met by Director Jihan Massoud. At 9:25am, LPA was provided a tour of the facility.

Census was taken. There were 2 Staff and 10 Children in Room 2, 2 Staff and 12 Children in Room 3, 3 Staff and 8 Children in Room 4, and 2 Staff and 13 Children in Room 5.

The report which has been amended was originally dated 11/12/2021.

No citations have been issued during today's inspection.

Exit interview was conducted with Director Jihan Massoud at 9:45am, copy of report was provided.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative.

END OF REPORT

SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1