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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320051
Report Date: 04/14/2022
Date Signed: 04/18/2022 09:53:38 AM

Document Has Been Signed on 04/18/2022 09:53 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PEPPER TREE ASSISTED LIVINGFACILITY NUMBER:
198320051
ADMINISTRATOR:KLEIN, STEPHANIEFACILITY TYPE:
740
ADDRESS:2353 251ST STREETTELEPHONE:
(310) 947-2165
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: DATE:
04/14/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Mila Santos, House ManagerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) conducted an unannounced POC case management visit to the above facility. LPA met with Mila Santos, House Manager and the purpose of the visit was explained.

LPA was shown all the medication for R1 with all pharmacy labels, including over the counter medication.
LPA cleared there outstanding POC.

An exit interview was conducted with Mila Santos, House Manager and copy of report was emailed. Due to technical difficulties.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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