<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601822
Report Date: 12/20/2021
Date Signed: 12/20/2021 02:13:30 PM

Document Has Been Signed on 12/20/2021 02:13 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:SPECIALIZED RESIDENTIAL MONTELLANOFACILITY NUMBER:
198601822
ADMINISTRATOR:CUA-KIM, JANEFACILITY TYPE:
735
ADDRESS:2767 MONTELLANO AVETELEPHONE:
(626) 961-2824
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 3DATE:
12/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Interim Administrator-Angela Williams TIME COMPLETED:
02:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Wong conducted a Case Management (Other) site visit to the facility to ascertain information pertaining to the Special Incident Report (occurred on 11/01/2021). LPA met with Staff #1 Janet Trujillo who allowed entry into the facility and was later met by the Interim Administrator Angela Williams who assisted with the visit.

During the visit, LPA interviewed the Interim Administrator in the facility and District Manager on the phone and gathered the information for client#1 (C1) including face sheet, admission agreement, Individual Program Plan (IPP), Physician Report dated on 01/20/2021, people's care quarterly report for C1 and the current address for C1 and staff#1(S1) included employee application and in service training record. LPA aslo toured the facility and the facility is clean and appeared in a good condition. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables and emergency preparedness storage containers of food supply.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.

An exit interview was conducted, a copy of the Report were provided to Interim Administrator- Angela Williams.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1