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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601489
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:22:01 PM

Document Has Been Signed on 10/31/2024 03:22 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CARRIE'S BOARD AND CAREFACILITY NUMBER:
197601489
ADMINISTRATOR/
DIRECTOR:		CARRIE ACOSTAFACILITY TYPE:
740
ADDRESS:8430 COLBATH AVENUETELEPHONE:
(818) 893-7619
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 4DATE:
10/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Carrie AcostaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:03 AM to conduct an unannounced Case Management visit at the facility today. LPA met with facility staff and contacted the facility Administrator. The facility Administrator Carrie Acosta arrived at 09:27 AM. The LPA advised the Administrator of the reason for the visit.

During an interview the LPA conducted with Resident #2 (R2), R2 informed the LPA that there is not a working telephone for resident use at the facility. During the physical plant tour LPA observed a phone in the kitchen. LPA and R2 attempted to use the phone to call the LPAs cell phone. LPA observed the facility phone to fail to make a call to the LPAs cell phone. LPA asked the facility Administrator Carrie Acosta to use the facility phone to make a phone call. The facility Administrator attempted to make a call but was unsuccessful. The facility Administrator stated that they were unaware that the phone was out of order and agreed to have it fixed.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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Document Has Been Signed on 10/31/2024 03:22 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/31/2024 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2024
Section Cited
CCR
87311

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87311 Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.
This requirement is not met as evidenced by:
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Licensee will submit proof of a functioning facility telephone to CCLD no later than POC due date.
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Based on interviews and observation the licensee failed to comply with the section cited above as the facility's telephone was observed to fail to make telephone calls which poses a potential personal rights and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


LIC809 (FAS) - (06/04)
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