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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610211
Report Date: 03/01/2022
Date Signed: 03/01/2022 10:38:30 AM

Document Has Been Signed on 03/01/2022 10:38 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:KITTRIDGE RCFEFACILITY NUMBER:
197610211
ADMINISTRATOR:MARTIR, FRANCISFACILITY TYPE:
740
ADDRESS:20702 KITTRIDGE STTELEPHONE:
(818) 854-6745
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 4DATE:
03/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Francis Martir TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Pitz conducted a scheduled prelicensing visit on this day.

LPA arrived at the facility and was greeted by administrator Francis Martir. LPA utilized the RCFE Prelicensing Inspection tool to review all eleven inspection domains. The following issues to be corrected were identified:

-LPA was unable to inspect locked garage during visit, administrator to obtain key from landlord and schedule virtual inspection with LPA.

Component III was conducted during the visit.

This report will be sent to the Centralized Application Bureau (CAB) You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under this license until you have been notified that your license has been approved by the CAB analyst. Failure to comply could affect approval of your license.


Report reviewed, signed and delivered. Exit interview conducted.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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