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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004356
Report Date: 11/04/2024
Date Signed: 11/04/2024 10:16:42 AM

Document Has Been Signed on 11/04/2024 10:16 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:INTEGRATED LIFEFACILITY NUMBER:
306004356
ADMINISTRATOR/
DIRECTOR:		CORINA M. DE LEONFACILITY TYPE:
775
ADDRESS:3634 ATLANTIC AVENUETELEPHONE:
(562) 726-1037
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 30CENSUS: 16DATE:
11/04/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Carina De Leon - Executive Director TIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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On 11/04/24 from 9:26 am to 10:15 am, Licensing Program Analyst( LPA) Ernand Dabuet initiated a Collateral visit at this facility. LPA met with Executive Director Corina DeLeon. LPA explained the purpose of this visit is to gather information regarding a current complaint about Emily's HomeCare Complaint number 11-AS-20241030170214.

The investigation visit consisted of an interview with client #1 (C1) and Executive Director witness #1 (W1). (C1) who currently resides as a consumer at Emily's HomeCare #198320223. Details of the interviews are documented on LIC 812 crossed reference with Emily's HomeCare (dated: 11/04/24).

An exit interview was conducted with Corina DeLeon, and copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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