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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004298
Report Date: 08/22/2023
Date Signed: 08/29/2023 08:21:04 AM

Document Has Been Signed on 08/29/2023 08:21 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SANDRA'S HOUSEFACILITY NUMBER:
306004298
ADMINISTRATOR:SANDRA BENSONFACILITY TYPE:
735
ADDRESS:2821 E. 57TH ST.TELEPHONE:
(562) 470-6300
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 4CENSUS: 4DATE:
08/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Administrator Anabel BerovinosTIME COMPLETED:
04:00 PM
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On 8/22/23, licensing program analyst (LPA) Lizeth Villegas conducted a case management visit in response to special incident report submitted to CCLD on 8/22/23 for incident occurring on 8/21/23; regarding client #1 assaulting client #2.

During today's visit LPA Villegas Conducted a health and safety visit which consisted of the following: LPA toured physical plant. obtained copies of resident #1's (Facesheet, physicians report, med list, IPP, behavior plan, incident reports for the last 6 months), resident roster, and staff roster.

Due to insufficient information available at this time, the above allegations need further follow up.

No immediate health and safety issues were observed.

Exit interview conducted with Administrator Anabel Berovinos, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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