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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602128
Report Date: 07/21/2023
Date Signed: 07/21/2023 12:31:02 PM

Document Has Been Signed on 07/21/2023 12:31 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:VOCATIONAL INNOVATIONSFACILITY NUMBER:
198602128
ADMINISTRATOR:PATEL, MANDAKINIFACILITY TYPE:
775
ADDRESS:1532 E SAN BERNARDINO B1-B5TELEPHONE:
(909) 971-3280
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 60CENSUS: 22DATE:
07/21/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Noe Rodriguez, Program DirectorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) conducted a collateral visit to interview Client #1 (C-1). LPA met with Program Director, Noe Rodriguez and explained the reason for the visit.

LPA only interviewed C-1 regarding an incident that occurred at the licensed home where C-1 resides.

A copy of this report was provided to the Program Director.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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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