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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600426
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:17:20 AM

Document Has Been Signed on 11/14/2024 11:17 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:C-H #5 RESIDENTIAL FACILITYFACILITY NUMBER:
198600426
ADMINISTRATOR/
DIRECTOR:		JEFFERSON, REBEKAHFACILITY TYPE:
735
ADDRESS:14750 WIEMER AVETELEPHONE:
(562) 634-4151
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 3CENSUS: 0DATE:
11/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Maxine HartwellTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced Case Management Visit- due to the closure of the facility. Upon arrival, an individual who stated he was from the construction company allowed entry into the home. The individual stated that there were no staff, or clients here any longer.

Licensee Maxine Hartwell had mailed in a copy of the facility license and a letter stating that there have been no clients at the home since 10/21/2024.

LPA Trueman conducted a tour of the single-story facility included the living room, kitchen, dining area, 3 client bedrooms, 2 bathrooms, laundry area, recreational room, front yard, backyard, and attached garage.
LPA did not observe any staff or clients and all rooms and bathrooms were observed to be under construction.
LPA contacted telephonically at today's visit Licensee Maxine Hartwell who confirmed the home is under construction and there are no clients as of 10/21/2024.
Also stated that the original license was submitted to Licensing on 10/21/2024.
Report e-mailed to Licensee for signature who was not at the home at the time of the visit.


No violations were observed during visit

.Exit interview was conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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