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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800633
Report Date: 01/13/2025
Date Signed: 01/27/2025 03:02:52 PM

Document Has Been Signed on 01/27/2025 03:02 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ST JOHN OF GOD RESIDENCEFACILITY NUMBER:
191800633
ADMINISTRATOR/
DIRECTOR:		SABRINA TUCKERFACILITY TYPE:
740
ADDRESS:2468 SO. ST. ANDREWS PLACETELEPHONE:
(323) 731-0641
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY: 40; 40CENSUS: 31DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Arjene Aguirre - Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 01/13/24, LPA conducted an annual inspection. LPA met with the Administrator Arjene Aguirre and the purpose of today’s visit was explained.
The annual visit consisted of the following: The department requested and obtained copies of the staff roster, resident roster, face sheet, physicians report, preplacement appraisal information, needs and service plan, personal rights.

Due to insufficient time, the annual inspection will have to continue at a later time. An exit interview was conducted with Administrator Arjene Aguirre and a copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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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