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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320318
Report Date: 05/24/2023
Date Signed: 05/24/2023 09:09:03 AM

Document Has Been Signed on 05/24/2023 09:09 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MARTHA'S HOUSE LLCFACILITY NUMBER:
198320318
ADMINISTRATOR:HYMES, SHARINAFACILITY TYPE:
740
ADDRESS:2422 E. 113 ST.TELEPHONE:
(323) 381-0025
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY: 4CENSUS: 0DATE:
05/24/2023
TYPE OF VISIT:POCANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Tiara JonesTIME COMPLETED:
09:00 AM
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On 05/24/23, Licensing Program Analyst (LPA), Alfonso Iniguez, conducted an announced visit to the listed facility above. LPA met with Tiara Jones, and discussed the purpose of today's visit.

During today's visit LPA Iniguez and Tiara Jones walked the grounds. LPA inspected the garage, and observed that the garage is no longer being used as a living space. The space is being utilized according to facility sketch. LPA Iniguez observed only a refrigerator inside the garage.

During this pre-licensing inspection, LPA did not find additional corrections are needed. LPA conducted the Component III Orientation with the Tiara Jones and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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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