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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601715
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:10:15 PM

Document Has Been Signed on 12/01/2022 04:10 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:MORIAH'S BOARD AND CAREFACILITY NUMBER:
198601715
ADMINISTRATOR:LILIBETH ESGUERRA-NUCKOLLSFACILITY TYPE:
735
ADDRESS:2054 LORAINE STTELEPHONE:
(626) 964-4980
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 4DATE:
12/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:44 PM
MET WITH:Lilibeth EsguerraTIME COMPLETED:
04:15 PM
NARRATIVE
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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) non-ambulatory to four (4) non-ambulatory clients. LPA met with Administrator Lilibeth Esguerra and explained the purpose of the visit. The facility is licensed to serve developmentally disabled clients (ages 18 through 59 years). The fire safety inspection for a capacity decrease was granted by Inspector G.Layton of the West Covina Fire Department on 11/30/2022.

LPA toured the facility to observe the facility sketch changes. Bedroom #1 - #4 will be private bedrooms. The office room was converted to bedroom #3. The office room is now located in the former staff room adjacent to the kitchen. Bedroom #1 & bedroom #2 have exit doors to the exterior of the facility.

On October 26, 2022, the San Gabriel/Pomona Regional Center provided a capacity decrease support letter. The last annual inspection was conducted on 7/27/2022. Two (2) deficiencies were observed at the time of the visit and have been cleared.

A new facility license with the capacity change will be mailed to Licensee. 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: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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