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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191604266
Report Date: 08/31/2022
Date Signed: 08/31/2022 03:23:07 PM


Document Has Been Signed on 08/31/2022 03:23 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:JOURNEY OF FAITHFACILITY NUMBER:
191604266
ADMINISTRATOR:NANCY KIMFACILITY TYPE:
850
ADDRESS:1243 ARTESIA BOULEVARDTELEPHONE:
(310) 374-0583
CITY:MANHATTAN BEACHSTATE: CAZIP CODE:
90266
CAPACITY:165CENSUS: 0DATE:
08/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Director , Nancy Kim TIME COMPLETED:
03:40 PM
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On 8/31/2022 Licensing Program Analyst (LPA) Dalicia Adkins conducted a case management visit and met with licensee, Nancy Kim. During visit facility was closed and no children present.

During case management visit it was determined that licensee did not report incident occurred on June 20, 2022- UIR Neglect/lack of Supervision to licensing by telephone or fax within the department next business day. Director Kim submitted verbal incident on 7/27/2022.

Title 22 reporting requirements; (a)The licensee shall report the following information to the Department by telephone or fax within the Department’s next business day and during normal working house 8am-5pm.

LPA provided technical assistance and Advisory- Technical Violation (TV) given. Refer to TV LIC 9102TV. Licensee acknowledges that incidents shall be reported meeting licensing reporting requirements.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources.
Exit interview conducted, copy of this report provided and reviewed with licensee.
SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Dalicia AdkinsTELEPHONE: (424) 301-3064
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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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