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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800697
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:36:37 PM


Document Has Been Signed on 04/16/2024 02:36 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:MY FAMILY RESIDENTIAL CARE HOMEFACILITY NUMBER:
425800697
ADMINISTRATOR:ANNIE MENDIOLAFACILITY TYPE:
740
ADDRESS:514 W. MCELHANEY AVE.TELEPHONE:
(805) 925-7836
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 6DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Administrator Michelle TantingcoTIME COMPLETED:
03:00 PM
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 At 2:05pm on 04/16/2024, Licensing Program Analyst's (LPA's) Rankin and Jeffries arrived unannounced to the facility to conduct the facility annual inspection. LPA's met with facility administrator Michelle Tantingco, announced who they are and the reason for the visit.

LPA's conducted a physical inspection of facility. LPA's, due to time constraints need to conclude the remainder of the inspection today. LPA's will return to continue the annual inspection at a later.

Exit interview, report read and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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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