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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197419097
Report Date:
11/07/2019
Date Signed:
11/08/2019 10:58:49 AM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO
,
CA
90245
FACILITY NAME:
PETITE SCHOOL HOUSE
FACILITY NUMBER:
197419097
ADMINISTRATOR:
SALMEENA ZAKI
FACILITY TYPE:
850
ADDRESS:
17643 ROSCOE BLVD.
TELEPHONE:
(818) 708-8766
CITY:
NORTHRIDGE
STATE:
CA
ZIP CODE:
91325
CAPACITY:
182
CENSUS:
DATE:
11/07/2019
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:00 PM
MET WITH:
Zaki Salmeena
TIME COMPLETED:
01:00 PM
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Margarit Sislyan arrived at the facility to conduct an annual visit.
Due to unexpected circumstances LPA could not complete the inspection.
Exit interview
SUPERVISOR'S NAME:
Mary Ruiz
TELEPHONE:
(424) 301-3061
LICENSING EVALUATOR NAME:
Margarit Sislyan
TELEPHONE:
(424) 430-3049
LICENSING EVALUATOR SIGNATURE:
DATE:
11/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/07/2019
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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