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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603279
Report Date: 04/01/2022
Date Signed: 04/01/2022 02:58:13 PM

Document Has Been Signed on 04/01/2022 02:58 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MINI MANOR HOMEFACILITY NUMBER:
198603279
ADMINISTRATOR:RUDES, MIRIAMFACILITY TYPE:
740
ADDRESS:1606 S. HOLT AVETELEPHONE:
(424) 284-3258
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY: 6CENSUS: 4DATE:
04/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Eilat NahumTIME COMPLETED:
01:36 PM
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On 04/01/2022 Licensing Program Analyst (LPA) Antonia Alvizar and Licensing Program Manager (LPM) Ulysess Coronel conducted a Case Management - Health and Safety Check to the above and met with Eilat Nahum Administrator.

During today visit LPA and LPM conducted a tour of the facility and interviewed R2 and R3 who were former residents of Beit Shalom #197608630.

No deficiencies were cited. A copy of this report was provided to Eilat Nahum, Licensee.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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