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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610253
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:16:35 AM

Document Has Been Signed on 08/03/2022 11:16 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:ASSURECARE HOME INCFACILITY NUMBER:
197610253
ADMINISTRATOR:PELEGRINO, FLORENCE CFACILITY TYPE:
740
ADDRESS:16729 TULSA STTELEPHONE:
(747) 239-3219
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 3DATE:
08/03/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Florence Pelegrino/ AdministratorTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct a pre-licensing visit. LPA was greeted by the facility administrator upon entry and had his temperature taken and covid -19 protocols taken before being allowed entry.

This facility application is a change of ownership and there were 3 residents at the time of the visit. The LPA was able to tour the home inside and out. There are 5 bedrooms, of which 4 will be used for residents and one will be a staff room. LPA did observe that the facility sketch did indicate that room 5 is a private resident room, however the administrator stated that this is an error and will be used as the staff room.

LPA was able to check the water temperature and it measured at 105 degrees F. The smoke alarms and carbon monoxide detectors were tested and functioned properly.

Component III Conducted. Pre-licensing Inspection tool review all eleven inspection domains, no deficiencies were observed.

Licensee will submit an updated physical plant sketch to CAB.

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

Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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