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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320397
Report Date: 11/09/2023
Date Signed: 11/09/2023 09:15:58 AM


Document Has Been Signed on 11/09/2023 09:15 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:DIVINE LIFE GUEST HOMEFACILITY NUMBER:
198320397
ADMINISTRATOR:ROSALDO, RODRIGOFACILITY TYPE:
740
ADDRESS:1711 W. 243RD ST.TELEPHONE:
(310) 310-1851
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 0DATE:
11/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Rodrigo Rosaldo/LicenseeTIME COMPLETED:
09:14 AM
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On 11/9/2023 at 8:50 AM LPA Alfonso Iniguez conducted an announced Pre-license correction visit at this facility. LPA met with licensee Rodrigo Rosaldo who assisted with this visit.

During this visit, LPA together with licensee toured the facility. LPA observed more board games in the living room and the new facility sketch form CAB was updated.


LPA conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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