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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603564
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:38:24 PM

Document Has Been Signed on 03/01/2023 03:38 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:MANSION AT WESTLAKEFACILITY NUMBER:
198603564
ADMINISTRATOR:PUNO-RIVERA, CARMANCITAFACILITY TYPE:
740
ADDRESS:1223 SOUTH ALVARADO STREETTELEPHONE:
(818) 804-0822
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY: 24CENSUS: 0DATE:
03/01/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Judy Agabin - House Manager TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores and Erik Zaragoza conducted an unannounced health check case management visit at the home. LPAs met with Kevin Parker volunteer and explained the reason for the visit.

LPA Flores conducted a tour of the home and observed the following:
LPAs observed rooms #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#11(R11),#12(R12).
LPAs observed 14 beds were being occupied at the time of the visit, (13) individuals were present during the visit and (1) person was out in the community.
During this visit (1) new person was admitted, who does not required care and supervision. (3) individuals from the last visit are no longer at the facility. (1) person is at the hospital, (2) individuals moved out.

Exit interview was conducted with Judy Agabin - House Manager and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2023
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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