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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606597
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:02:00 PM


Document Has Been Signed on 03/29/2023 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
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: 11DATE:
03/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teodora CambiadoTIME COMPLETED:
01:30 PM
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On 03/29/2023 at 9:00 a.m. Licensing Program Analysts (LPAs) Evelin Rios and Gary Tan conducted an unannounced case management visit at this facility to follow-up with the facilities closure plan and to interview residents. LPAs met with staff Teodora Cambiado whom provided subsequent information regarding placement, eviction notices and how the facility is following closure plan. LPAs reviewed 11 out of 11 residents relocation information and signed eviction notices for 10 out 11 with one refused to sign.

LPAs conducted physical plant tour at 9:08 AM, requested copy of facility documents at 9:45 AM and interviewed residents and staff between 9:30 AM to 1:00 PM.

During the tour and interview, LPAs observed that four (4) out of the eleven (11) residents were picked up by their respective subsequent living location. The rest of the residents have an arranged location destination per LPAs' interview with the Teodora Cambiado. LPAs interview with Teodora confirmed relocation location for the rest of the residents will be completed by tomorrow March 30, 2023.

Staff was made aware if closure plan is not followed as specified a citation may be issued and possible civil penalties may be assessed. 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: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
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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