<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198320002
Report Date:
01/17/2023
Date Signed:
01/17/2023 02:10:35 PM
Document Has Been Signed on
01/17/2023 02:10 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:
HOME SWEET HOME LA
FACILITY NUMBER:
198320002
ADMINISTRATOR:
WILLIAMS, TRACY
FACILITY TYPE:
735
ADDRESS:
1218 W 106TH ST
TELEPHONE:
(323) 696-9331
CITY:
LOS ANGELES
STATE:
CA
ZIP CODE:
90044
CAPACITY:
6
CENSUS:
DATE:
01/17/2023
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
C1-C3
TIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/17/23 at 1:00pm, LPA Perry Scott conducted a collateral visit to Ideal Program to interview C1-C3 unrelated to the day program.
SUPERVISORS NAME
:
Janae Hammond
LICENSING EVALUATOR NAME
:
Perry Scott
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/17/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1