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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610651
Report Date: 08/22/2024
Date Signed: 08/23/2024 09:38:04 AM

Document Has Been Signed on 08/23/2024 09:38 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ST. PAUL RCFEFACILITY NUMBER:
197610651
ADMINISTRATOR/
DIRECTOR:		OBTINALLA, ARNIDAFACILITY TYPE:
740
ADDRESS:22235 WYANDOTTE STREETTELEPHONE:
(818) 448-2967
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 5DATE:
08/22/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Mc Richard Obtinalla (Licensee) Arnida Obtinalla (Administrator) TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census : 5
Method: Telephone call with CAB

COMP II Participants: Mc Richard Obtinalla (Licensee) Arnida Obtinalla (Administrator) & Tammy Edwards (Analyst).
Licensee & administrator participated in COMP II via Telephone call with CAB Analyst. Identification
of licensee/administrator was verified by confirming driver’s license numbers. During COMP II,
licensee/administrator confirmed the understanding of Title 22. Component II was successfully
completed. Licensee/administrator were advised to email signed LIC 809 with copy of photo ID to
CAB.

During COMP II, CAB analyst confirmed licensee's/administrator’s understanding of following
areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Tammy Edwards
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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