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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601959
Report Date: 01/21/2025
Date Signed: 01/21/2025 12:44:02 PM

Document Has Been Signed on 01/21/2025 12:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOM & DAD'S HOUSEFACILITY NUMBER:
198601959
ADMINISTRATOR/
DIRECTOR:		IVONNE A. MEADERFACILITY TYPE:
740
ADDRESS:4340 CONQUISTA AVE.TELEPHONE:
(562) 627-0390
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 6CENSUS: 6DATE:
01/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:19 PM
MET WITH:Jose Umana - Acting AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control # 28-AS-20250113161518). The purpose of this visit is to issue deficiency that was observed by LPA that is not part of the complaint allegation.

During the visit on 01/21/2025, LPA spoke with the Administrator, Ivonne Meader on the phone and stated that she is out of town. Administrator confirmed that she did not inform CCL of her temporary absence nor submitted a designation of facility responsibility form to CCL. However, Administrator stated that she has designated, Jose Umana as Administrator (Tel: 818-606-6136) in her absence and will fax CCL the designation of facility responsibility (LIC308) immediately.

Deficiency is noted on LIC 809D. Exit interview, a copy of this report and Appeals Rights were provided to Jose Umana, Acting Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/21/2025 12:44 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/21/2025 at 12:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOM & DAD'S HOUSE
FACILITY NUMBER: 198601959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
HSC
1569.618(a)

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1569.618 ...Administration and management of residential care facilities; ..(a) The administrator designated by the licensee pursuant to paragraph...shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.
This requirement is not met as evidenced by:
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The Administrator shall ensure to assign an acting Administrator to be responsible for the operation of the facility when the administrator is temporarily absent from the facility. Administrator agreed to fax the Designation of facility responsibility (LIC308) to CCL/LPA by POC due date.OC due date.
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Administrator is out of town and did not submit Designation of Facility Responsibility to CCL to notify who the contact/Administrator responsible for the facility in her absence which poses/posed a potential health, safety or personal rights risk to residents in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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