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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320312
Report Date: 07/07/2023
Date Signed: 07/07/2023 04:28:57 PM

Document Has Been Signed on 07/07/2023 04:28 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CASA DEL SURFACILITY NUMBER:
198320312
ADMINISTRATOR:AGATEP, EVANGELINEFACILITY TYPE:
740
ADDRESS:343 E 228TH STREETTELEPHONE:
(310) 787-7300
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 0DATE:
07/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Glenda BustosTIME COMPLETED:
02:31 PM
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On 07/07/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent prelicensing inspection visit. LPA met with applicant Glenda Bustos and explained the purpose of the visit is to inspect the corrections were identified on the initial prelicesing visit on 06/29/23.

The corrections that were made as follows:
  • Incomplete First Kit (completed 07/07/23)
  • No First Aid Manuel (completed 07/07/23)
  • Room #1 window screen needs to be replaced (completed 07/07/23)
  • Room #1 window covering needs to be correct size or replaced (completed 07/07/23)
  • Room #4 cracked window located next to sliding door (window ordered - waiting for parts)
  • Room #2 screen door needs DW-40 or replaced (completed 07/07/23)
  • Required perishable food (completed 07/07/23)
  • Thermometers for refrigerator & freezer (completed 07/07/23)
  • Water Heater (no hot water) - (completed 07/07/23 - 106.1 F)
  • Stove front burner non-operable (completed 07/07/23)
  • Facility Menu & Activity/Board Games (completed 07/07/23)
  • Included in today's inspection a covered outdoor seating for four with a table.


An exit interview was conducted, and a copy of this report has been furnished to the applicant, Glenda Bustos . LPA Dabuet will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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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