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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608258
Report Date: 07/08/2021
Date Signed: 07/08/2021 08:57:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LEISURE LIVING OF CLAREMONTFACILITY NUMBER:
197608258
ADMINISTRATOR:KATHLEEN GONZALESFACILITY TYPE:
740
ADDRESS:1738 FINECROFT DRIVETELEPHONE:
(626) 622-7296
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 5DATE:
07/08/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Melanie ThaiTIME COMPLETED:
09:05 AM
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Licensing Program Analysts (LPAs) David Sicairos and Luis Mora conducted an unannounced collateral visit in an attempt to interview Resident #1 (R1). LPAs met with staff member Melanie Thai and explained the reason for the visit.

No deficiencies cited during visit. Exit interview held and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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