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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601822
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:02:35 PM

Document Has Been Signed on 09/08/2023 03:02 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SPECIALIZED RESIDENTIAL MONTELLANOFACILITY NUMBER:
198601822
ADMINISTRATOR:DONOVAN COVINGTONFACILITY TYPE:
735
ADDRESS:2767 MONTELLANO AVETELEPHONE:
(626) 961-2824
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 4DATE:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Janet De Luna - House ManagerTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced case management visit to the facility. The purpose of today’s visit was to serve the Order to Licensee of Immediate Exclusion from Facility for Staff #1 (S1) and Staff #2 (S2). An investigation by the California Department of Social Services was conducted and it was determined that S1 and S2 violated California Code of Regulations Title 22 for Personal Rights.

In addition, LPA is also serving the Order to Licensee of Immediate Exclusion from Facility for the following Staff and Facilities: S1 for People's Care Cameron #198602123 and S2 for Specialized Residential Hargis #197608587 (El Segundo Regional Office), all locations share the same LLC, therefore, serving at one facility.

On today's visit LPA met with Janet De Luna and explained the reason for the visit. Janet De Luna was provided with copies of the Order to Licensee of Immediate Exclusion and Order to Individual for Immediate Exclusion letters and Government Code 11522.

Exit interview held. A copy of the report was provided to Janet De Luna.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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