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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204621
Report Date: 04/26/2023
Date Signed: 04/26/2023 04:04:52 PM


Document Has Been Signed on 04/26/2023 04:04 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:SEDONA GUEST HOMEFACILITY NUMBER:
198204621
ADMINISTRATOR:ANTONIO ARBOLEDAFACILITY TYPE:
740
ADDRESS:21635 HOWARD STREETTELEPHONE:
3107929020
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 0DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Nicanor Santos - CaregiverTIME COMPLETED:
04:23 PM
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On 04/26/2023 Licensing Program Analyst (LPA) Mario Leon and Licensing Program Manager (LPM) Ulysses Coronel conducted an unannounced annual inspection visit at the above facility. The team was met by Nicanor Santos and Jennifer Mape, caregivers.

During today's inspection a physical plant tour was conducted with Mr. Santos. LPA conducted facility, staff and resident records review.

During today's visit, there were no deficiencies cited. Due to time constraints, an unannounced subsequent annual inspection will be conducted.

An exit interview and a copy of this report was provided to Mr. Santos.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
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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