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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198603188
Report Date:
01/06/2024
Date Signed:
01/06/2024 09:34:26 AM
Document Has Been Signed on
01/06/2024 09:34 AM
- 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 ASC
,
1000 CORPORATE DR #100
MONTEREY PARK
,
CA
91754
FACILITY NAME:
BRUCE & NELSON RESIDENTIAL FACILITY
FACILITY NUMBER:
198603188
ADMINISTRATOR:
NELSON, KENDRA D
FACILITY TYPE:
735
ADDRESS:
1722 WEST 165TH STREET
TELEPHONE:
(424) 785-5412
CITY:
COMPTON
STATE:
CA
ZIP CODE:
90220
CAPACITY:
4
CENSUS:
2
DATE:
01/06/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:00 AM
MET WITH:
Kendra Nelso
TIME COMPLETED:
09:40 AM
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On 1/6/2024 at around 8:00 AM Licensing Program Analyst (LPA) Socorro Leandro met with Licensee Kendra Nelson and due to unforeseen circumstances LPA was unable to complete annual inspection.
SUPERVISORS NAME
:
Ulysses Coronel
LICENSING EVALUATOR NAME
:
Socorro Leandro
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/06/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/06/2024
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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