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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005564
Report Date: 02/10/2021
Date Signed: 02/10/2021 03:04:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MASTERSON SENIOR HOMEFACILITY NUMBER:
306005564
ADMINISTRATOR:NGUYEN, TRANGFACILITY TYPE:
740
ADDRESS:10290 MASTERSON AVETELEPHONE:
(657) 256-1641
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:6CENSUS: 0DATE:
02/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA met with Tenant. LPA introduced self and stated the purpose of the visit.

On December 7, 2020, Community Care Licensing Division Orange Regional Office received the original copy of the facility license and a letter from Administrator Trang Nguyen describing that the facility was closed and she was surrendering the license. She also provided a copy of the lease agreement that LPA request from prior phone interviews with AD Nguyen.

About 11:30 AM, LPA Marin confirmed with Tenant that they have been in the property since November 2020. Tenant lives with family members as described in the lease agreement. After the interview, LPA requested permission to check the facility to ensure that there were no residents in care. Tenant granted verbal permission. LPA checked all the bedrooms and common areas of the facility and did not observe any resident in care. LPA thanked Tenant for the accommodation and time.

LPA Marin will provide a copy of this report to AD Trang Nguyen. A read receipt will confirm that the report have been received by the Administrator.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021
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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