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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610305
Report Date: 08/05/2022
Date Signed: 08/05/2022 10:34:44 AM

Document Has Been Signed on 08/05/2022 10:34 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: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: 0DATE:
08/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ayedeh Allahdadi/ AdminTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and was greeted by the facility administrator and the administrator's consultant. This visit was held in order to conduct a pre licensing inspection. This is a new application and there were no residents at the facility during the visit.

The home is a six bed 3 bath, house. Four bedrooms and three bathrooms are located on the downstairs level. The upstairs level will be for staff only and there was a child proof door that restricts access to the upstairs. On the first level, there are two private rooms and two shared rooms.

The facility was inspected for fire safety and all smoke alarms and carbon monoxide detectors were tested and functioned properly. LPA toured the home inside and out and no issues were observed.

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

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: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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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