<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421700369
Report Date: 04/30/2021
Date Signed: 04/30/2021 03:58:17 PM

Document Has Been Signed on 04/30/2021 03:58 PM - 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ATTERDAG VILLAGE OF SOLVANGFACILITY NUMBER:
421700369
ADMINISTRATOR:CHRIS PARKERFACILITY TYPE:
741
ADDRESS:636 N ATTERDAG ROADTELEPHONE:
(805) 688-3263
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 188CENSUS: 95DATE:
04/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Jaime LugoTIME COMPLETED:
03:54 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/30/2021 at 2:51pm, Licensing Program Analyst (LPA) Diaz spoke with Jaime Lugo, the Director for Assisted and Independent Living. LPA explained the purpose of today’s visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted virtually.

The televisit was in response to an incident regarding Resident 1 (R1) being absent without leave. LPA toured the facility and interviewed the Director. The Director stated that they will provide LPA with additional documents regarding the incident.

Exit interview conducted, no citations issued, copy of report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1