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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603124
Report Date: 09/10/2021
Date Signed: 09/10/2021 04:00:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LA POSADA IN GLENDORAFACILITY NUMBER:
198603124
ADMINISTRATOR:DIAZ, RAFAELFACILITY TYPE:
740
ADDRESS:1239 S SUNFLOWER AVETELEPHONE:
(562) 774-7167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 6DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Santos Valencia, CaregiverTIME COMPLETED:
04:10 PM
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Licensing Program Analyst's (LPA's) Vasallo and Mora conducted an annual visit. LPA's met with Santos Valencia, caregiver. Administrator, Rafael Diaz was called and notified of the visit. LPA's used the infection control tool to inspect the facility. LPA's toured the facility and observed 6 residents in care and 2 staff. The kitchen was toured. All appliances are working properly and there is sufficient perishable and non-perishable food. Bathrooms have the required grabs and the hot water was between 115 - 118 degrees. Facility was clean and there were no health and safety concerns at the time of the visit.

LPA's will return at a later date to complete the inspection and conduct a file review.

Exit interview held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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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