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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610163
Report Date: 08/19/2021
Date Signed: 08/20/2021 07:15:47 AM

Document Has Been Signed on 08/20/2021 07:15 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:A & V SENIOR CAREFACILITY NUMBER:
197610163
ADMINISTRATOR:GONZALEZ, LORENAFACILITY TYPE:
740
ADDRESS:14928 HIAWATHA STREETTELEPHONE:
(818) 921-0589
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY: 6CENSUS: 5DATE:
08/19/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Lorena GonzalezTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an announced pre licensing. LPA entry to facility temperature check was done. Applicant showed LPA facility posters that were outdated for the current licensee. The checklist for pre licensing was delayed since CCL did not have the proper email address. LPA reviewed with applicant the necessary forms to update and complete.

The files on hand were all for Garner home, The LPA will reschedule this visit since new applicant did not have all covid signage and updates done on paperwork.


Exit interview conducted. The applicant will contact LPA when all documentation and physical plant is ready.
LPA will send signage by email.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Angelica Arambulo
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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