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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608641
Report Date: 04/25/2023
Date Signed: 04/25/2023 11:16:29 AM


Document Has Been Signed on 04/25/2023 11:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:PINK CORAL RESIDENCE IIFACILITY NUMBER:
197608641
ADMINISTRATOR:REX RETOLADOFACILITY TYPE:
740
ADDRESS:40343 N. 15TH STREET WESTTELEPHONE:
(661) 480-5985
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 6DATE:
04/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rey MedelTIME COMPLETED:
10:45 AM
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LPA Spaeth arrived and was greeted by caregiver at 9:00 am. The Licensee/Administrator arrived to the facility at 9:10 am. LPA stated the purpose of the visit was regarding an incident report dated 4/15/2023. Licensee confirmed there are six residents.

LPA and Licensee toured facility at 9:25 am until 9:45 am. LPA did not observe any health or safety issues.

LPA interviewed the resident (R1) at 9:45 am until 10:00 am and interviewed the Licensee at 10:15 am until 10:25 am. LPA confirmed with R1 and the Licensee that R1 fell on 4/12/2023 and went to the hospital on 4/15/2023. LPA confirmed with the Licensee the date was incorrect on the incident report. During LPA's visit, the Licensee corrected the incident report and LPA obtained a copy of the corrected report.

There are no deficiencies to report at this time. Exit interview coneucted, and a copy of the signed report was given to the Licensee.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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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