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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608920
Report Date: 03/22/2022
Date Signed: 03/22/2022 11:47:34 AM

Document Has Been Signed on 03/22/2022 11:47 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:OCEAN GARDENS III, LLCFACILITY NUMBER:
197608920
ADMINISTRATOR:CATHRIA BORKOWSKIFACILITY TYPE:
740
ADDRESS:1249 23RD STREET, #ATELEPHONE:
(310) 315-3040
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY: 6CENSUS: 0DATE:
03/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Joy Wood-AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Stephanie Cifuentes, conducted an announced case management visit to the facility named above. LPA Cifuentes met with Administrator Joy Wood. LPA Cifuentes informed the administrator that the purpose of today's visit is to conduct a walkthrough of the facility and collect the license for a licensee-initiated closure.

Administrator Joy Wood gave LPA a tour through the inside and outside of the facility grounds, The facility is a one-story structure located in a residential neighborhood. The facility is a one-story structure located in a residential neighborhood. The facility grounds consists of the following: (3) resident bedrooms, (1) bathrooms, living room, dining room, kitchen and office. There is an outdoor covered lounge area. There were no clients present in the facility at the time of inspection. Clothes were not found in closets or dressers and linens had been stripped from the beds.

Resident 1- Resident 3 (R1-R3) have moved to the following locations: R1: Kalnel Assisted Living 11237 Lucerne Ave. Culver City, Ca 90230. R2: Josephine's Garden VIlla- 521 N Rowelle Ave. Manhattan Beach, Ca. R3: Miko Inn 3017 Malcolm Ave. Los Angeles, Ca 90034.

Administrator Joy Wood surrendered the license to LPA Cifuentes at the end of the visit.

Exit interview was conducted and a copy of this report was provided to Mrs. Wood at the end of the visit.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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