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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198320228
Report Date:
01/19/2022
Date Signed:
01/19/2022 06:37:56 PM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1000 CORPORATE DR #100
MONTEREY PARK
,
CA
91754
FACILITY NAME:
PACIFIC ADULT CARE
FACILITY NUMBER:
198320228
ADMINISTRATOR:
FERGUSON, AARON
FACILITY TYPE:
740
ADDRESS:
8755 WEST OLYMPIC BLVD
TELEPHONE:
(323) 809-0591
CITY:
LOS ANGELES
STATE:
CA
ZIP CODE:
90035
CAPACITY:
150
CENSUS:
0
DATE:
01/19/2022
TYPE OF VISIT:
Prelicensing
UNANNOUNCED
TIME BEGAN:
11:35 AM
MET WITH:
AARON FERGUSON
TIME COMPLETED:
12:40 PM
NARRATIVE
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On 1/19/22 at 11:35 AM Licensing Program Analyst (LPA) Martessa Brown met with Aaron Ferguson to conduct the prelicense visit. LPA toured the facility and Administrator is not ready to be licensed at this time.
SUPERVISOR'S NAME:
Janae Hammond
TELEPHONE:
(323) 981-3328
LICENSING EVALUATOR NAME:
Martessa Brown
TELEPHONE:
(714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE:
01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/19/2022
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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