<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602255
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:45:07 PM

Document Has Been Signed on 07/14/2023 03:45 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - DOMINGUEZ HOMEFACILITY NUMBER:
198602255
ADMINISTRATOR:ROSAS, CLAUDIOFACILITY TYPE:
735
ADDRESS:214 E DOMINGUEZTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 3CENSUS: 3DATE:
07/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Yesenia VargasTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/11/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with Yesenia Vargas . LPA explained the purpose of today’s visit. The facility is licensed to operate for three (3) non-ambulatory ages 18 through 59. The clients are Harbor Regional Center consumers.

During the visit LPA did audit of client's #1-#3 (C1-C3) service files P&I resources and it revealed to be complete. Interviews were conducted with (2) clients. Client #3 was unavailable for an interview as client was out in the community.

Due to unforeseen circumstances, the administrator is unavailable to be at the facility and DSP Vargas will need to leave to pick up client from Day Program. No one will be at the home from 1:30 pm - 4:00 pm.

An Annual inspection continuation will be conducted a later date.

An exit interview conducted with Yesenia Vargas and a copy of the report provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1