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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700790
Report Date: 03/01/2022
Date Signed: 03/01/2022 10:10:56 AM

Document Has Been Signed on 03/01/2022 10:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:LIFE CARE PROVIDERSFACILITY NUMBER:
194700790
ADMINISTRATOR:SHAWN EDWIN VAUGHN JRFACILITY TYPE:
300
ADDRESS:8889 W OLYMPIC BLVDTELEPHONE:
(310) 801-7161
CITY:BEVERLY HILLSSTATE: CAZIP CODE:
90211
CAPACITY: CENSUS: DATE:
03/01/2022
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Leonirita AmandaTIME COMPLETED:
10:00 AM
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Life Care Providers on 3/1/2022. Upon arrival, the HCSB analyst identified himself and was greeted by Leonirita Amanda. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with Leonirita and informed the licensee that no discrepancies were found.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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