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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601934
Report Date: 12/18/2024
Date Signed: 12/18/2024 09:28:16 AM

Document Has Been Signed on 12/18/2024 09:28 AM - 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CBG HOME INC.FACILITY NUMBER:
198601934
ADMINISTRATOR/
DIRECTOR:		NEEKOLE GLASPIEFACILITY TYPE:
735
ADDRESS:13413 S. VAN NESS AVENUETELEPHONE:
(310) 327-2531
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 4DATE:
12/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Carlos Santino, Direct Support Professional
TIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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On 12/18/24, Licensing Program Analyst (LPA) Felisa Shirley visited this facility to verify that S-1 is no longer employed at this facility. LPA Shirley spoke to S-2 and S-3 they stated that S-1 has not been working here since early 2024. LPA Shirley spoke with the Administrator, Kim Cooper and the purpose for the visit was discussed. Exit Interview Conducted with S-2.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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