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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426141
Report Date: 10/23/2023
Date Signed: 10/23/2023 03:29:11 PM

Document Has Been Signed on 10/23/2023 03:29 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:HALCYON PLACE IFACILITY NUMBER:
366426141
ADMINISTRATOR:MARYA ALPERTFACILITY TYPE:
740
ADDRESS:6947 KIRKWOOD AVENUETELEPHONE:
(951) 818-6667
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 5DATE:
10/23/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Victor & Eva TancincoTIME COMPLETED:
03:29 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for the purpose of completing a Health & Safety check. LPA met with care providers Victor and Eva Tancinco who were informed of the purpose of the visit. Eva Tancinco (Eva) phoned administrator Marya Alpert and Alpert spoke with LPA on the phone.

LPA conducted staff and resident interviews. LPA and staff Eva toured the interior of the home. LPA observed all utilities appear to be operable. Food supply observed to be sufficient for residents in care. During the visit, LPA observed some residents in their room resting while some in facility common areas. LPA observed residents eating in the dining area.

No imminent health/safety concerns were observed. Residents in care appeared to be safe with no imminent health/safety concerns. The facility was maintained at a comfortable temperature for the residents in care. The needs of the residents in care appeared to be met during the inspection.

An exit interview was conducted and a copy of this report was provided to staff Tancinco
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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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