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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606597
Report Date: 03/15/2023
Date Signed: 03/15/2023 12:52:11 PM


Document Has Been Signed on 03/15/2023 12:52 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:WESTPORT HOMEFACILITY NUMBER:
197606597
ADMINISTRATOR:REX RETOLADOFACILITY TYPE:
740
ADDRESS:10252 EAST AVENUE STELEPHONE:
(661) 944-5779
CITY:LITTLEROCKSTATE: CAZIP CODE:
93543
CAPACITY:20CENSUS: DATE:
03/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Teodora CambiadoTIME COMPLETED:
01:15 PM
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On 03/15/2023 at 11:00 a.m. Licensing Program Analysts (LPAs) Evelin Rios and Tuesday Cabiness conducted an unannounced case management visit at this facility to obtain information pertaining to the facility closure plan. LPAs met with staff Teodora Cambiado whom provided information regarding placement, eviction notices and how the facility plans to initiate the closure plan. LPAs obtained 11 out 11 resident's relocation information and signed eviction notices for 10 out 11 with one refusal to sign. LPA requested within 48 hours in writing the facility closure plan and must be submitted to LPA Rios. Staff was made aware if closure plan is not submitted a citation may be issued and possible civil penalties may be accessed. A physical plant tour was conducted



Exit interview conducted. Copy of this report issued
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
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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