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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600290
Report Date: 01/23/2024
Date Signed: 01/23/2024 05:46:36 PM


Document Has Been Signed on 01/23/2024 05:46 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ASUNCION BOARD & CAREFACILITY NUMBER:
198600290
ADMINISTRATOR:ROSEMARIE A. ZIMMERFACILITY TYPE:
740
ADDRESS:1636 S. RAMA DRIVETELEPHONE:
(626) 338-0772
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY:6CENSUS: 4DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Administrator Rosemarie TIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an Annual Required visit and inspection of the facility. LPA met with the Administrator Rosemarie A Honrado and Licensee Adelaida Asuncion. LPA explained the purpose of the visit.
The facility is licensed to serve Dementia residents, ages 60 and above, approved for two (2) non-ambulatory and four (4) ambulatory residents. Currently, there is no hospice resident in placement.
During the visit, LPA toured the facility inside and outside, and reviewed 2 residents files. LPA requested and obtained a copies of residents files.
The facility is a single-story house located in a residential neighborhood. It consists of five (5) bedrooms including three (3) resident bedrooms, one (1) staff room, one (1) room for family member; three (3) bathrooms, kitchen, dining room, living room, and detached garage.

Due to insufficient time and information during the visit at this time, LPA will return at a later time to complete annual inspection. Exit interview was conducted with Adelaida Asuncion and the copy of this report provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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