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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801861
Report Date: 05/09/2024
Date Signed: 05/09/2024 04:02:52 PM

Document Has Been Signed on 05/09/2024 04:02 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ESTRELL HOME CARE LLCFACILITY NUMBER:
425801861
ADMINISTRATOR/
DIRECTOR:		RUBY Q. MARTINEZFACILITY TYPE:
740
ADDRESS:804 LAVONNE DRIVETELEPHONE:
(805) 354-0670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 3CENSUS: 2DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Estrellita Martinez - Designated Back-upTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) De Leon and Rankin arrived at 09:40am to conduct a 1 year annual visit to the facility above. LPA met Estrellita Martinez and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Designated Back-up Administrator, Estrellita.

LPA's reviewed staff files, reviewed training, medications, and resident files.

Additional time is needed to complete annual visit and interviews.

Exit interview conducted and copy of report printed for back-up administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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