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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201597
Report Date: 01/10/2025
Date Signed: 01/10/2025 10:58:38 AM

Document Has Been Signed on 01/10/2025 10:58 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ANA'S ELDERLY CARE HOMEFACILITY NUMBER:
198201597
ADMINISTRATOR/
DIRECTOR:		RAMOS, ANA MARIAFACILITY TYPE:
740
ADDRESS:3906 TULLER AVENUETELEPHONE:
(310) 398-9305
CITY:CULVER CITYSTATE: CAZIP CODE:
90230
CAPACITY: 6CENSUS: 0DATE:
01/10/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ana RamosTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On _01/10/25__, Licensing Program Analyst (LPA) Yolanda Rosser__ conducted an announced required inspection. LPA met with Licensee/ Administrator, _Ana Ramos_. LPA explained the purpose of today’s visit. The facility is licensed for Six (6) non-ambulatory clients of which one (1) bedridden (1) one Hospice Resident. 60 yrs. old and above. Census is zero (0).

Administrator, Ramos is closing facility due to last client passing away as of October 21,2024.

Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: Five (5) client's rooms, Four(4) bathrooms, living room, dining area, kitchen, and an office area and den areas.


Bedrooms: Bedroom C was inspected, there were a few bags(3) that were due to be picked up by the Trustee or donated if need be. (Very few personal effects, clothes, shoes, socks)which will be disposed of as soon as the trustee picks them up. All other items items were previously picked up by the Trustee.

All medication was destroyed and all records will be maintained for 3 years per protocol.

An exit interview was conducted and a copy of this report was left with Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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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