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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592479
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:30:37 PM


Document Has Been Signed on 05/04/2023 12:30 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ATRIA COVINAFACILITY NUMBER:
191592479
ADMINISTRATOR:ALONDRA FUENTESFACILITY TYPE:
740
ADDRESS:825 W SAN BERNARDINO RDTELEPHONE:
(626) 967-9621
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:90CENSUS: 98DATE:
05/04/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Alondra Fuentes - AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Mora conducted a collateral visit to this facility. The purpose of this visit is to interview the Administrator as a part of a complaint investigation (control number: 28-AS-20220421101842). Once the interview ended, the visit was completed.

Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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