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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600956
Report Date: 05/20/2021
Date Signed: 05/21/2021 03:23:55 PM

Document Has Been Signed on 05/21/2021 03:23 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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME:PRISCILLA'S HOMEFACILITY NUMBER:
198600956
ADMINISTRATOR:BETH KAZUYE FIGUEROAFACILITY TYPE:
735
ADDRESS:2505 WEST 180TH STREETTELEPHONE:
(310) 538-9978
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 4CENSUS: 4DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Patrick FigueroaTIME COMPLETED:
11:30 AM
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On 5/20/21, Licensing Program Analyst/ Susan Campos, was allowed entry into the facility by Licensee, Patrick Figueroa, and LPA informed Mr. Figueroa, the purpose of the visit was to conduct a Infection Control Inspection of the facility.

LPA and Mr. Figueroa toured the residential home with 5 bedrooms, (1bedroom staff usage) and 2 bathroom, and reviewed the facility mitigation plan.

No deficiencies cited.

An exit interview was conducted, and a LIC 809 was provided to Licensee Patrick Figueroa.
Eva M Alvarez
Susan Campos
DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
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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