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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603550
Report Date: 05/04/2023
Date Signed: 05/04/2023 11:15:18 AM


Document Has Been Signed on 05/04/2023 11:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:WEST PARK SENIOR LIVINGFACILITY NUMBER:
198603550
ADMINISTRATOR:IRBY, LORIFACILITY TYPE:
740
ADDRESS:801 CYPRESS WAYTELEPHONE:
(626) 339-5426
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:200CENSUS: 113DATE:
05/04/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Lori Irby - Executive DirectorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Mora conducted a collateral visit to this facility. The purpose of this visit is to interview the Executive Director and Business Office Manager as a part of a complaint investigation (complaint control #28-AS-20220421101842). Once the interviews ended, the visit was completed.

Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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