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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609684
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:11:20 PM

Document Has Been Signed on 02/27/2023 04:11 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:SUNNYBRAE HOMEFACILITY NUMBER:
197609684
ADMINISTRATOR:SAVELLA, JEFFREYFACILITY TYPE:
740
ADDRESS:8001 SUNNYBRAE AVETELEPHONE:
(323) 455-7821
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 5DATE:
02/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Jeffrey SavellaTIME COMPLETED:
04:15 PM
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On 02/27/23, Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced case management visit due to an incident reported on 02/18/23. LPA met with facility staff and explained the reason for this visit. The administrator was contacted and arrived later.

LPA Smith conducted a physical plant tour at approximately 1:20 pm to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit.

LPA conducted interview with administrator at approximately 1:50 pm – 2:55 pm and requested copies of pertinent documents relevant to the investigation.

Further investigation is required at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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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