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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610397
Report Date: 04/07/2023
Date Signed: 04/07/2023 02:15:32 PM

Document Has Been Signed on 04/07/2023 02:15 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ICON-ADPFACILITY NUMBER:
197610397
ADMINISTRATOR:BROWN, DEWALTFACILITY TYPE:
775
ADDRESS:2369 LINCOLN AVETELEPHONE:
(626) 923-3519
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 120CENSUS: DATE:
04/07/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
02:14 PM
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COMP II by CAB successfully completed

Facility Type: ADC
Application Type: Initial
Capacity: 120
Census (if any clients in care): 0
Method: Telephone call with CAB
COMP II Participants: Dewalt Brown, Administrator/Owner; Shannon Betker, analyst.

Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Staff training
4. Applicant and Administrator qualifications
5. Grievances, Complaints
6. Application document review and technical assistance: Pre-licensing inspection
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Shannon Betker
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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