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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604809
Report Date: 10/17/2022
Date Signed: 10/18/2022 01:46:48 PM

Document Has Been Signed on 10/18/2022 01:46 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHATEAU MAGNOLIAFACILITY NUMBER:
197604809
ADMINISTRATOR:KARINE FILIKYANFACILITY TYPE:
740
ADDRESS:1061 EAST MAGNOLIA ST.TELEPHONE:
(818) 843-5873
CITY:BURBANKSTATE: CAZIP CODE:
91501
CAPACITY: 6CENSUS: 4DATE:
10/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Karine FilikyanTIME COMPLETED:
01:31 PM
NARRATIVE
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This report is being written separately as it is not part of the complaint dated 4/18/2022

During the course of the complaint investigation on 4/26/2022 and while interviewing staff, It was discovered that S2 did not have background Clearance nor associated with facility.

Licensee has been cited and civil penalties issued, please 809D for details.


Exit interview conducted and copy of report will be emailed to Licensee due to printer issues
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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Document Has Been Signed on 10/18/2022 01:46 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/17/2022 at 10:51 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/24/2022
Section Cited
CCR
87219(e)

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Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
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Administrator will obtain background clerance associated S2 prior to working at facility. S2 was sent home during visit. Civil penanty assesesd $100
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This requirement was not met as evidenced by:

Based on interview, record review and observation, 1 sttaff S2, did not have background clerance or assosicated with facility.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
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