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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608511
Report Date: 09/28/2021
Date Signed: 09/28/2021 12:58:59 PM

Document Has Been Signed on 09/28/2021 12:58 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:CASA BLANCA HOMECAREFACILITY NUMBER:
197608511
ADMINISTRATOR:MARILOU A. ANDREASFACILITY TYPE:
740
ADDRESS:17216 GOYA STREETTELEPHONE:
(818) 366-2234
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 3DATE:
09/28/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Marilou Andreas/ AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home in order to conduct an infection control annual. LPA, Gary Tan, completed an infection control annual at this location on 7/23/21, therefore the annual was not needed.

LPA did tour the home for health and safety and no concerns were observed. There was a sufficient amount of food, both perishable and nonperishable food properly stored at the home.

No health and safety concerns were observed during the visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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