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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603798
Report Date: 02/11/2025
Date Signed: 02/11/2025 01:52:46 PM

Document Has Been Signed on 02/11/2025 01:52 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EVELYN'S MANORFACILITY NUMBER:
198603798
ADMINISTRATOR/
DIRECTOR:		HALLMAN, KAYLONFACILITY TYPE:
740
ADDRESS:1126 E 82ND STREETTELEPHONE:
(310) 739-9303
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 6CENSUS: 0DATE:
02/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:44 PM
MET WITH:Applicant Kaylon HallmanTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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LPA Gutierrez made a follow up visit to the pre-licensing conducted on 02/06/2025. During the visit LPA observed working telephone, CPR/First Aid Manual, and Complaint poster PUB 475. No outstanding or pending items were observed. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.

Exit interview held and a copy of the report was provided to applicant Kaylon Hallman.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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