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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608922
Report Date: 03/02/2022
Date Signed: 03/02/2022 12:30:42 PM

Document Has Been Signed on 03/02/2022 12:30 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:OCEAN GARDENS V, LLCFACILITY NUMBER:
197608922
ADMINISTRATOR:VICTORIA TSOYFACILITY TYPE:
740
ADDRESS:1247 25TH STREETTELEPHONE:
(424) 238-8319
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY: 6CENSUS: 0DATE:
03/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Joy WoodTIME COMPLETED:
11:30 AM
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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 walk through 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 consists of the following: (3) resident bedrooms, (2) 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 -Sunrise Senior Living-Playa Vista 5555 Playa Vista Drive. Los Angeles, Ca 90994. R2: Kalnel Assisted Living 4630 Sawtelle Blvd. Culver City, Ca 90230. R3: My Mothers Place 11827 Rose Ave. Los Angeles, Ca 90066

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 Joy Wood at the end of the visit.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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