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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600880
Report Date: 07/13/2022
Date Signed: 07/13/2022 04:01:25 PM

Document Has Been Signed on 07/13/2022 04:01 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:INDIVIDUAL OPTIMUM LIFESTYLE APPROACHFACILITY NUMBER:
198600880
ADMINISTRATOR:ALICIA WALTERSFACILITY TYPE:
735
ADDRESS:1811 N ALLEN AVETELEPHONE:
(626) 791-1495
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 3DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Staff Members / Ivan Montgmoery, Kimberly Garcia & Heidy Flores
Facility Supervisor / Norma Tovar Loya		TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Staff members / Ivan Montgomery, Kimberly Garcia and Heidy Flores and was later joined by the Facility Supervisor / Norma Tovar Loya who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled Clients ages 18 - 59 years. The facility is approved for two (2) Non-Ambulatory Clients. Currently, there are three (3) clients in placement.

During today's visit, LPA toured the physical plant areas (outside only) to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is located in a residential area. The front yard is well landscaped with steps and/or a ramp that leads to the entry. A shaded area with chairs is provided in the back yard. The trash cans have covered lids. There are no weapons on the premises. There is a detached garage which is being used as a storage.

Due to time constraints, LPA had to terminate visit and will return on a later date to complete the Required - 1 Year inspection.
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No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to the Facility Supervisor.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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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