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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601885
Report Date: 01/27/2025
Date Signed: 01/27/2025 12:29:45 PM

Document Has Been Signed on 01/27/2025 12:29 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:GRAYBURN HOMEFACILITY NUMBER:
198601885
ADMINISTRATOR/
DIRECTOR:		ELAINE MILLERFACILITY TYPE:
735
ADDRESS:2973 GRAYBURN STTELEPHONE:
(909) 596-5360
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
01/27/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Irene "Susie" Gallardo/S-1 and LaTonya King TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a Case Management visit to obtain additional information on a special incident involving C-1. LPA was allowed entry by Irene "Susie" Gallardo/Staff #1/S-1. LPA discussed the purpose of today's visit. LaTonya King (Administrator) arrived at approximately 11:40 A.M..

During this visit, LPA obtained a copy of the staff and client rosters and LPA reviewed C-1's file and obtained relevant documentation. LPA obtained staff contact information and contact information for Quality Assurance from San Gabriel Pomona Regional Center. LPA was unable to interview Client #1 (C-1) through Client #4 (C-4) as they are non-verbal. LPA interviewed S-1 and the Administrator. LPA conducted a tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats.

Per special incident report, on 01/17/25, C-1 was diagnosed with a leg fracture (unknown how injury occurred). LPA to conduct additional interviews and may request additional documentation.

Exit interview conducted and a copy of this report was provided to LaTonya King.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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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