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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602619
Report Date: 04/12/2023
Date Signed: 04/12/2023 06:19:34 PM

Document Has Been Signed on 04/12/2023 06:19 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:ACOSTA FAMILY HOME IIIFACILITY NUMBER:
198602619
ADMINISTRATOR:ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:875 S ARANBE AVETELEPHONE:
(310) 554-4824
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 6CENSUS: 2DATE:
04/12/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Sayra Ramos TIME COMPLETED:
02:30 PM
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On 04/12/23 Licensing Program Analyst( LPA) Ernand Dabuet initiated a Collateral visit at this facility. LPA met with Direct Support Provider Sayra Ramos . LPA explained the purpose of this visit is to gather information regarding a current complaint about ACOSTA FAMILY HOME II Complaint number 11-AS-20230406123315.

The investigation consisted of collecting service records for client #1-#2 (C1-C2). The following records were obtained:
  • Facility Employee Schedule
  • Face Sheet
  • Register of Facility Client
  • Physician's Report
  • Client Development Evaluation Report
  • Functional Capability Assessment
  • ID and Emergency Information
  • Staff Communication Log
  • Behavior Data

Details of the record reviews are documented on LIC 812 crossed reference with Acosta Family Home II.

An exit interview was conducted with Sayra Ramos, and a hard copy was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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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