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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603585
Report Date: 05/19/2023
Date Signed: 05/19/2023 08:33:36 AM


Document Has Been Signed on 05/19/2023 08:33 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HENRIETTA'S HOMEFACILITY NUMBER:
198603585
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 703-4958
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:6CENSUS: 4DATE:
05/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Maura Pizarro, CaregiverTIME COMPLETED:
08:35 AM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced case management visit for the purpose of amending complaint report #: 28-AS-20221212100233 (12/12/2022). The purpose of the visit was explained to caregiver Maura Pizarra and to Administrator Robin Aquino telephonically. Corrections to the complaint report were made.

No health and safety issues were observed during today's physical plant tour.


Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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