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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602076
Report Date: 01/03/2025
Date Signed: 01/03/2025 11:31:04 AM

Document Has Been Signed on 01/03/2025 11:31 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EMPOWER UNLIMITED POTENTIALFACILITY NUMBER:
198602076
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, ELLISSETFACILITY TYPE:
775
ADDRESS:6713 SEVILLE AVETELEPHONE:
(323) 770-4440
CITY:HUNTINGTON PARKSTATE: CAZIP CODE:
90255
CAPACITY: 50CENSUS: 44DATE:
01/03/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:48 AM
MET WITH:Supervisor Heliezer EspinozaTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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LPA Gutierrez conducted a case management visit to interview client who was at day program at time of visit to C1's home.LPA met with Supervisor Heliezer Espinoza and explained reason for visit.

LPA was able to interview C1 and S3 during todays visit exit interview was conducted and a copy of this report was given to Heliezer Espinoza.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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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