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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610305
Report Date: 07/29/2022
Date Signed: 07/29/2022 11:40:36 AM

Document Has Been Signed on 07/29/2022 11:40 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:BRIGHTSTAR SENIOR CARE,INCFACILITY NUMBER:
197610305
ADMINISTRATOR:ALLAHDADI, AYEDEHFACILITY TYPE:
740
ADDRESS:10455 GAYNOR AVETELEPHONE:
(818) 517-0544
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: DATE:
07/29/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ayedeh Allahdadi(Applicant/Administrator)TIME COMPLETED:
11:27 AM
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Facility Type: RCFE
Application Type: INITIAL
Capacity: 6
Census (if any clients in care): 0

COMP II Participants: Ayedeh Allahdadi(Applicant/Administrator)
Interview Method: Telephone interview with CAB

During COMP II, Applicant/Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Applicant and Administrator qualifications
3. Staffing requirements & Training
4. Program policies -restricted/prohibited health conditions; abuse reporting, incident reporting to CCLD; food service management; emergency procedures; activities programs
5. Grievances, Complaints, Community resources
6. Application document review and technical assistance- Criminal record clearance; Health screening; Fire clearance; First aid/CPR certificate; Administrator certificate; Financial verification; Compliance history; Control of property
SUPERVISORS NAME: Tracy Thompson
LICENSING EVALUATOR NAME: Ricmar Soriano
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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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