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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602174
Report Date: 08/31/2022
Date Signed: 08/31/2022 03:42:04 PM

Document Has Been Signed on 08/31/2022 03:42 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALLEN'S PALM COVE CERRITOSFACILITY NUMBER:
198602174
ADMINISTRATOR:DIMAANO, EUPHROSYNEFACILITY TYPE:
740
ADDRESS:18714 KINGS ROW AVETELEPHONE:
(562) 866-3585
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 4DATE:
08/31/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Euphrosyne Dimaano & Peter NoraTIME COMPLETED:
03:56 PM
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Licensing Program Analyst (LPA) David Sicairos and Regional Manager (RM) Araceli Ramirez conducted a Case Management follow up visit to follow up on the items discussed during the visit conducted on 08/26/22. LPA & RM met with Euphrosyne Dimaano and Peter Nora.

During today's visit, the following was discussed: LPA, RM, and Administrators met with C1 to discuss the next steps in relocation to a higher level of care facility. C1 will be transferred to Agape Congregate living on 09/01/22. This facility is licensed under the Department of Public Health. C1 has agreed to the transfer. Transportation has been arranged for 10am tomorrow.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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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