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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603470
Report Date: 09/08/2023
Date Signed: 09/08/2023 01:33:52 PM

Document Has Been Signed on 09/08/2023 01:33 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:SPECIALIZED RESIDENTIAL COVINA BLVD.FACILITY NUMBER:
198603470
ADMINISTRATOR:NELSON RIVERAFACILITY TYPE:
738
ADDRESS:146 SOUTH COVINA BOULEVARDTELEPHONE:
(909) 287-3557
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 2DATE:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Alexandria Moreno - House LeadTIME 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
Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced case management visit to the facility. The purpose of today’s visit was to serve the Order to Licensee of Immediate Exclusion from Facility for Staff #1 (S1) and Staff #2 (S2). An investigation by the California Department of Social Services was conducted and it was determined that S1 and S2 violated California Code of Regulations Title 22 for Personal Rights.

In addition, LPA is also serving the Order to Licensee of Immediate Exclusion from Facility for the following Staff and Facility: Peoples Care Lomitas #198603467 for S1. (both facilities share the same LLC, therefore, serving at one facility)

On today's visit LPA met with Alexandria Moreno and explained the reason for the visit. Alexandria Moreno was provided with copies of the Order to Licensee of Immediate Exclusion and Order to Individual for Immediate Exclusion letters and Government Code 11522.

Exit interview held. A copy of the report was provided to Alexandria Moreno.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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