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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609947
Report Date: 11/30/2022
Date Signed: 11/30/2022 11:21:04 AM

Document Has Been Signed on 11/30/2022 11:21 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:PRIMROSE 3FACILITY NUMBER:
197609947
ADMINISTRATOR:NAIMUDDIN, MUBEENFACILITY TYPE:
740
ADDRESS:17537 BLYTHE STREETTELEPHONE:
(323) 872-2755
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 6DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Mubeen Naimuddin/ AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility inn order to conduct an infection control annual. The LPA was greeted by facility staff and had his temperature taken and covid-19 questions asked before being allowed entry. The LPA explained the reason for the visit and the administrator was called. The administrator arrived a short while later.

The LPA was able to test the carbon monoxide detectors and the smoke alarms and they functioned properly. The fire extinguisher was observed in the kitchen area and was in the green and appeared functional. The home consists of 5 bedrooms and 3 bathrooms. The inspection tool was used to conduct the annual and no deficiencies were observed.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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