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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006491
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:24:54 PM

Document Has Been Signed on 09/13/2024 04:24 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:STANTON BOARD AND CARE HOMEFACILITY NUMBER:
306006491
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, GREGFACILITY TYPE:
735
ADDRESS:8296 STANTON AVENUETELEPHONE:
(714) 816-5043
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: DATE:
09/13/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Greg and Diana HernandezTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Facility Type: ARF
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Greg (A) and Diana Hernandez (C)
Interview Method: Telephone interview

On September 13, 2024, applicant/administrator participated in COMP II. Identification of the
applicant and administrator was verified through interview questions based on photo ID and
other identifying personal information. During COMP II, applicant and administrator confirmed
that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following
areas:
1. Facility operation: License type, client/resident populations, and program
2. Activities/Day Program/ Unusual Incidents
3. Medications/Transportation
4. Pre Licensing Inspection readiness
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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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