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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609097
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:43:02 PM

Document Has Been Signed on 06/21/2024 04:43 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:THREE C'S CARE HOMEFACILITY NUMBER:
197609097
ADMINISTRATOR/
DIRECTOR:
LOPEZ, MILAGROSFACILITY TYPE:
740
ADDRESS:6447 BABCOCK AVENUETELEPHONE:
(818) 747-2212
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:Milagros Lopez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and met with Milagros Lopez, Administrator, The reason for today's visit was provided.

The facility is a single storey family home consisting of a living room, dining room, kitchen, three bedrooms, a private bathroom, a common bathroom and a detached garage. The facility is fire cleared for five(5) non-ambulatory and one(1) bedridden.

The following domains were reviewed on today's visit: Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Food Service, Incidental and Medical. 3 staff files and 6 resident files were reviewed. Due to time constraints the following domains will be reviewed on a return visit: Physical Plant/Environmental Safety, Resident Records/Incident Reports, Disaster Preparedness and Residents with Special Health Needs.

Per review of the domains noted above, staff files and resident files, no deficiencies were cited on today's visit.

Exit interview was conducted and a copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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