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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601604
Report Date: 05/10/2023
Date Signed: 05/10/2023 01:43:41 PM

Document Has Been Signed on 05/10/2023 01:43 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - 256TH HOMEFACILITY NUMBER:
198601604
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:1716 256TH STREETTELEPHONE:
(424) 263-4028
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 4CENSUS: 3DATE:
05/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:XIOMARA VANEGASTIME COMPLETED:
02:00 PM
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ON 05/10/23 LICENSING PROGRAM ANALYST(LPA) Antonine Richard conducted a Case Management visit regarding the passing of a Resident #1. LPA met with staff Xiomara Vanegas, and the purpose of the visit was explained.

LPA reviewed CCL's Regional Office records and observed that the facility is a four (4) bedrooms two (2) bathrooms, a living area a dining area and kitchen.

On the 5/10/23, LPA interviewed Staff surrounding Resident #1 death. LPA collected a copy of the Resident' records.

Based on documentation and interviews conducted, there is no deficiency cited

An Exit interview was conducted. A copy this report was given to Xiomara Vanegas
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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