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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803754
Report Date: 09/19/2024
Date Signed: 09/19/2024 03:04:00 PM


Document Has Been Signed on 09/19/2024 03:04 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:DOUGLAS RESIDENTIAL CAREFACILITY NUMBER:
197803754
ADMINISTRATOR:GLENDA D. MARQUEZFACILITY TYPE:
740
ADDRESS:5332 E GREENMEADOW ST.TELEPHONE:
(562) 420-3731
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:6CENSUS: 6DATE:
09/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Eduardo Pinawin, CaregiverTIME COMPLETED:
10:00 AM
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On 09/19/2024 at 9:00am , LPA Zina Brown conducted an unannounced continuation annual visit using the CARE Inspection Tool. LPA met Eduardo Pinawin (caregiver) with the purpose of today’s visit was explained.

LPA reviewed (6) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Eduardo Pinawin (Caregiver).
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina BrownTELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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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