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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607305
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:05:58 PM

Document Has Been Signed on 11/15/2024 12:05 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CARRILLO MANORFACILITY NUMBER:
197607305
ADMINISTRATOR/
DIRECTOR:		ROWENA MARANTAL-CARRILLOFACILITY TYPE:
740
ADDRESS:14006 SYLVANWOOD AVE.TELEPHONE:
(213) 281-1439
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 3DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:42 AM
MET WITH:Caregiver Nancy HernandezTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced Required 1 year inspection at the facility and met with Caregiver Nancy Hernandez and explained the purpose for todays visit.

Due to time constraints, LPA will terminated inspection and will return at a later date to complete all (12) CARE Tool domains. Exit interview conducted with Caregiver Nancy and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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