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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600271
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:15:13 PM

Document Has Been Signed on 07/25/2024 01:15 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/
DIRECTOR:		ADELA SANTOSFACILITY TYPE:
735
ADDRESS:948 SOUTH HAMILTON BLVD.TELEPHONE:
(909) 620-1933
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 84CENSUS: 61DATE:
07/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Adela Santos/S-1TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a Case Management Visit today regarding a special incident which occurred on 07/14/24 involving Client #1 (C-1). LPA reviewed file and obtained relevant documentation for C-1. LPA interviewed Ms. Santos/S-1.

LPA toured the facility grounds and did not observe any health and safety concerns. Ms. Santos will continue to keep LPA informed of any further developments pertaining to C-1's incident.

An exit interview was conducted and a copy of this report wa s given to Adela Santos
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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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