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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197607503
Report Date:
05/24/2022
Date Signed:
05/24/2022 12:18:02 PM
Document Has Been Signed on
05/24/2022 12:18 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
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
SUNLAND LIVING
FACILITY NUMBER:
197607503
ADMINISTRATOR:
JURATE EZERSKIENE
FACILITY TYPE:
740
ADDRESS:
11433 COLLETT AVE
TELEPHONE:
(818) 488-1998
CITY:
GRANADA HILLS
STATE:
CA
ZIP CODE:
91344
CAPACITY:
6
CENSUS:
5
DATE:
05/24/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:00 AM
MET WITH:
Greta Hernandez/ Caregiver
TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Patrick Shanahan arrived at this facility to conduct a One (1) year Required visit. LPA met with care staff and the administrator was called on the phone. Staff was informed the purpose of the visit.
LPA observed that all four (5) residents were in their respective bedrooms either watching TV and/or resting.
A tour of the physical plant was conducted with staff The facility has seven (7) bedrooms and six (6) bathrooms currently occupying five (5) residents. One (1) bedroom and one (1) bathroom is designated for staff use.
All smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguisher was observed and appeared functional/
The facility is currently following their mitigation plan. No deficiencies were observed during today's visit. Exit interview conducted and report issued.
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Patrick Shanahan
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/24/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2022
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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