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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005743
Report Date: 02/14/2022
Date Signed: 03/28/2022 12:40:48 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/28/2022 12:40 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ASSURED CARE VILLAFACILITY NUMBER:
306005743
ADMINISTRATOR:DOMPREH-MENSAH, THERESAFACILITY TYPE:
740
ADDRESS:561 EAST SECOND AVETELEPHONE:
(310) 650-4190
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 6CENSUS: 0DATE:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Theresa Dompreh-Mensah, Administrator (remotely)TIME COMPLETED:
10:21 AM
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At approximately 10:00am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch attempted to conduct a visit for the purpose of a required annual visit. Licensee Theresa Dompreh-Mensah responded via the connected doorbell and indicated the facility was not currently taking any residents in care. Facility appears vacant of both staff and residents.

An attempted visit is being logged . No facility representative was available to sign the report and therefore a copy of the report will be faxed to the licensee and a copy with hard signature will be retained on file.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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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