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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602875
Report Date: 12/15/2023
Date Signed: 12/15/2023 01:22:23 PM

Document Has Been Signed on 12/15/2023 01:22 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:CASA BARBARAFACILITY NUMBER:
198602875
ADMINISTRATOR:HENRY A LARAFACILITY TYPE:
735
ADDRESS:3453 LIBERTY BOULEVARDTELEPHONE:
(562) 682-9667
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 4CENSUS: 4DATE:
12/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Henry-Lara - AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced case management visit for the purpose of obtaining signature and delivering an amended complaint report #28-AS-20231121103815. LPA Pena was greeted by Henry Lara, Administrator and the purpose of the visit was explained. The corrections to the report were made and discussed with the Administrator.

Exit interview conducted and a copy of this report was provided to Henry Lara, Administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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