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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602377
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:11:15 PM

Document Has Been Signed on 07/18/2023 03:11 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:FAMILY CONNECT MEMORY CARE INCFACILITY NUMBER:
198602377
ADMINISTRATOR:SPIGLANIN, LAUREN MAHAKIANFACILITY TYPE:
740
ADDRESS:1747 GREENWOOD AVENUETELEPHONE:
(310) 383-1877
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 6DATE:
07/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Kristine SimonianTIME COMPLETED:
03:15 PM
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On 07/18/23, Liciensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced case management visit to the facility listed above. LPA met with Office Manager, Kristine Simonian, and explained the purpose of today's visit. Currently there are 6 Resident's in placement and all 6 Residents were home during the visit.

During today's visit, LPA conducted a tour of the facility. During the tour, LPA met with all staff on shift at the facility. LPA confirmed, Staff (S1) is not working at the facility. During file review, LPA found that Staff (S1) was employed at the facility from 10/11/21 through 08/22/22. Staff (S1) was disassociated from the facility on 07/18/23.

No deficiencies were observed or cited during today's visit.

An exit interview was conduct with Office Manager, Kristine Simonian, and a copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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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