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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320105
Report Date: 09/08/2021
Date Signed: 09/08/2021 06:29:20 PM

Document Has Been Signed on 09/08/2021 06:29 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:AVIATION GUEST HOMEFACILITY NUMBER:
198320105
ADMINISTRATOR:GALLIOS, WILLIAM V. IIFACILITY TYPE:
740
ADDRESS:317 S. AVIATION BLVDTELEPHONE:
(310) 533-1131
CITY:MANHATTAN BEACHSTATE: CAZIP CODE:
90266
CAPACITY: 6CENSUS: 6DATE:
09/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Gallios, WilliamTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Jey Cardenas and Licensing Program Manager (LPM) Angela Kendrick conducted an unannounced case management visit relating to complaint for facility Mansel Guest Home 2. which was received on 12/27/2019, Mansel Guest Home 2 went through a change of ownership and is now Aviation Guest Home. LPA Cardenas conducted risk assessment with Director, Yolanda Martinez via telephone. Facility is clear of Covid-19 infection.

LPA Cardenas and LPM Kendrick met with Mr.Gallios William and explained the purpose of todays visit was to review complaint and deficiencies cited for previous facility knowns as : Mansel Guest Home 2. Mr William indicated that Mansel Guest Home 2 is closed and he cant represent this entity, therefore he is unable to sing complaint report. MR. WIlliam refused to review and sign this case management report.

report to be provided to Mr. WIlliam via email.



SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
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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