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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608813
Report Date: 01/28/2022
Date Signed: 01/28/2022 11:05:30 AM

Document Has Been Signed on 01/28/2022 11:05 AM - 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 HOMECARE IIFACILITY NUMBER:
197608813
ADMINISTRATOR:MARIA LUISA ANDREASFACILITY TYPE:
740
ADDRESS:16411 GOTHIC PLACETELEPHONE:
(818) 363-6319
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 5DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:MARIA LUISA ANDREASTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) , Patrick Shanahan, arrived at the home and was greeted by facility staff. LPA observed that all staff and residents were wearing masks in the common areas.

The facility has 6 bedrooms and 4 bathrooms. The facility appeared clean and sanitary. The smoke alarms and carbon monoxide detectors were tested and appeared to be functioning properly. The fire extinguisher was observed in the kitchen and appeared to be functioning properly.

The facility is following their approved mitigation plan and no health and safety concerns were observed during todays visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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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