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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592693
Report Date: 05/30/2023
Date Signed: 05/30/2023 04:04:37 PM

Document Has Been Signed on 05/30/2023 04:04 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:UNITED CARE HOMESFACILITY NUMBER:
191592693
ADMINISTRATOR:JOCELYN TUBIANOSAFACILITY TYPE:
735
ADDRESS:702 LYONWOOD STREETTELEPHONE:
(909) 869-7754
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 6CENSUS: 6DATE:
05/30/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Luisa Larioza, StaffTIME COMPLETED:
04:05 PM
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) Cynthia Chan conducted an unannounced case management Plan of Correction visit to follow up on the deficiency that was issued during the annual inspection on 5/9/23. The purpose of the visit was explained to staff Luisa Larioza.

During the visit today, LPA observed Staff files maintained at the facility. LPA selected the Administrator plus 3 other Staff files for review. The files have current CPR/First aid training certificates, health screening with the TB results, job application, and the required annual training hours. The staff are all fingerprint cleared and associated to the facility.

No deficiencies were issued today and the POC will be cleared.

An exit interview was conducted and a copy of this report was given to Staff Larioza.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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