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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600768
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:19:12 PM

Document Has Been Signed on 01/23/2025 03:19 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MISS DAISY'S ADULT RESIDENTIALFACILITY NUMBER:
198600768
ADMINISTRATOR/
DIRECTOR:		BETTY BROWNFACILITY TYPE:
735
ADDRESS:1654 WEST 51ST PLACETELEPHONE:
(323) 296-7390
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY: 6CENSUS: 4DATE:
01/23/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Betty BrownTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 01/23/25 at 2:35pm, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced case management visit to Miss Daisy’s Adult Residential Facility. LPA was greeted by Betty Brown, Administrator, and the reason for the visit was explained.

During the visit, LPA request an address and telephone number for a previous resident (R1) that was transferred from this facility to another facility in response to a complaint investigation. Complaint # 11-AS-20241223144649. Administrator provided me with the information.

An exit interview was conducted a copy of the report was given to Betty Brown, Administrator.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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