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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290719
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:21:02 PM

Document Has Been Signed on 03/20/2025 03:21 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MOTHER GERTRUDE HOMEFACILITY NUMBER:
191290719
ADMINISTRATOR/
DIRECTOR:
SR. ELIA CAROFACILITY TYPE:
740
ADDRESS:11320 LAUREL CANYON BLVDTELEPHONE:
(818) 898-1546
CITY:SAN FERNANDOSTATE: CAZIP CODE:
91340
CAPACITY: 97CENSUS: 28DATE:
03/20/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:38 AM
MET WITH:Sister Elia Caro - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:19 PM
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Licensing Program Analysts (LPAs) Nadia Shahbazian conducted an unannounced site visit continuation of the required annual inspection conducted on 02/27/2025. LPAs met with Sister Elia Caro – Administrator, and explained the reason for the visit.

At 02:50pm LPA conducted a quick tour of the physical plant to ensure health and safety of residents. Facility bathrooms, surrounding areas and common areas are clean, sanitary and the equipment/furnishings are in good condition. The outdoor area was free of hazards, obstructions and compliant with Title 22 regulations.

Staff files: LPAs reviewed staff files to ensure staff has fingerprint clearance, association to the facility, and current 1-st Aid, CPR, and Crises Prevention Intervention (CPI) certification. A total of six (6) staff files were reviewed, all records appeared to be complete and current.



Resident files: LPAs reviewed client records to ensure their files include, but not limited to: Medical assessments, appraisals, emergency contact information, and admission agreements. A total of five (5) resident files were reviewed; all five (5) resident records appeared to be complete and current.

Pursuant to Title 22 Divisions the CA Code of Regulations, there were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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