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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600620
Report Date: 10/03/2024
Date Signed: 10/03/2024 10:09:36 AM

Document Has Been Signed on 10/03/2024 10:09 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:ESCOBAR ADULT RESIDENTIALFACILITY NUMBER:
198600620
ADMINISTRATOR/
DIRECTOR:		ESCOBAR, SYLVIA A.FACILITY TYPE:
735
ADDRESS:5916 BARTLETT AVENUETELEPHONE:
(626) 286-6768
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 4CENSUS: 4DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Sylvia Escobar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) N. Galarza conducted a case management visit to inspect the facility for a capacity decrease from six (6) ambulatory to four (4) ambulatory clients. The purpose of the visit was explained to Administrator Sylvia Escobar. The facility is presently licensed to serve developmentally disabled clients (ages 18 through 59 years) as a level 3 facility.

On 7/1/2024, the Regional Office received a capacity decrease request. The fire safety inspection for a capacity decrease was granted by M. Burciaga of County of Los Angeles Fire Department School/Institutions North Unit on 9/12/2024.

Room #1 will be shared by two (2) clients, and rooms #2 & # 3 will be private bedrooms for two (2) clients.

The Eastern Los Angeles Regional Center provided a capacity decrease support letter. The last CCLD annual inspection was conducted on 5/16/2024. There are no pending items of correction.

NOTE: Licensee/Administrator is waiting for a level change approval from 3 to 4C from the Regional Center and DDS.

A new facility license with the capacity change was issued today. Licensee was informed that the old license will be void.


Exit interview was conducted. A copy of the report was issued
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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