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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603607
Report Date: 12/19/2022
Date Signed: 12/19/2022 11:01:26 AM


Document Has Been Signed on 12/19/2022 11:01 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:SPRINGFIELD MANORFACILITY NUMBER:
198603607
ADMINISTRATOR:BAIG, SHAHBAZFACILITY TYPE:
735
ADDRESS:2526 NEW AVENUETELEPHONE:
(818) 846-4469
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:32CENSUS: 31DATE:
12/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teodulo Bonzon, applicantTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a follow up visit to complete the Pre-licensing inspection. LPA met with applicant, Teodulo Bonzon and Administrator, Dominique F. Shakramy.

On 12/5/22, LPA Chan conducted the initial Pre-licensing inspection and the following needed to corrected and/or clarified:
* The fire inspection indicated a clearance for 34 ambulatory adults. However, during the inspection, the additional rooms are located in a separate building that is fenced off and has a different address of 2530 New Avenue. This will require clarification due to the address for this license is at 2526 New Avenue.
* Food supplies of at least a week of non-perishable were not maintained at the facility.

During the visit today, LPA performed a final walk through.
* The licensee submitted a revised capacity change from 34 to 32. On 12/9/22, the fire clearance has been approved for a capacity of 32 ambulatory only adults.
* The non-perishable food supply of at least a week are observed in one of the garage space.

LPA conducted the component III today.

The Pre-licensing deficiencies have been resolved. Pre-licensing is now complete. An exit interview was held and a copy of this report was provided to Dominique Shakramy.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
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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