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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610397
Report Date: 07/31/2023
Date Signed: 07/31/2023 01:54:49 PM

Document Has Been Signed on 07/31/2023 01:54 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
Lookup Error,
, CA
FACILITY NAME:ICON-ADPFACILITY NUMBER:
197610397
ADMINISTRATOR:BROWN, DEWALTFACILITY TYPE:
775
ADDRESS:2369 LINCOLN AVETELEPHONE:
(626) 926-3519
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 120CENSUS: 103DATE:
07/31/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Assistant Administrator / Steven "Shay" JamesTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a collateral visit to this facility. Upon arriving at the facility, LPA met with Assistant Administrator / Steven "Shay" James who assisted with the visit. LPA explained the purpose for today's Collateral Case Management visit is to interview Client 1 (C1) regarding allegations unrelated to ICON - ADP.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
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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