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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600271
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:46:53 PM


Document Has Been Signed on 01/30/2024 12:46 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HAMILTON VILLAFACILITY NUMBER:
198600271
ADMINISTRATOR:ADELA SANTOSFACILITY TYPE:
735
ADDRESS:948 SOUTH HAMILTON BLVD.TELEPHONE:
(909) 620-1933
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY:84CENSUS: 64DATE:
01/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Adela Santos/AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a Case Management Visit today regarding a special incident which occurred on 01/22/2024 involving Client #1 (C-1). LPA reviewed file and obtained relevant documentation for C-1. LPA interviewed Ms. Santos/Administrator, S-1 and C-2.

LPA toured the facility grounds and did not observe any health and safety concerns.

An exit interview was conducted and a copy of this report was given to Adela Santos.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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