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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601110
Report Date: 05/24/2021
Date Signed: 05/24/2021 02:59:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GRACE ELDER CAREFACILITY NUMBER:
075601110
ADMINISTRATOR:BROUVWER, KYUNG H. PARKFACILITY TYPE:
740
ADDRESS:2610 FRANCISCO WAYTELEPHONE:
(510) 233-9693
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:6CENSUS: 0DATE:
05/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Not available, LicenseeTIME COMPLETED:
11:26 AM
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On 05/24/21 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit at the facility. When LPA arrived, a termite inspector was evaluating the home outside. LPA observed the front door was open and an eviction notice was posted on the front door along with a Sheriff's notice of eviction. Termite inspector stated that a realty company from Redondo Beach CA now owns the property.
LPA inspected the facility inside and outside. LPA observed no residents or staff present at the facility. No one was available to sign this report as the facility is empty of staff and residents.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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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