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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201168
Report Date: 05/27/2021
Date Signed: 05/27/2021 03:24:44 PM

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:VILLA SCALABRINI RETIREMENT CENTERFACILITY NUMBER:
191201168
ADMINISTRATOR:ADILSO LUIZ BALENFACILITY TYPE:
740
ADDRESS:10631 VINEDALE STREETTELEPHONE:
(818) 768-6500
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:130CENSUS: 79DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ardy AfsharTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Pitz conducted an unannounced infection control visit on this day. LPA was greeted upon arrival and screened for COVID-19 symptoms. LPA toured the facility and confirmed that a Covid Mitigation Plan has been submitted to the department. LPA utilized the Infection Control domain of the Adult Residential Facility inspection tool to confirm that the facility is following current infection control guidelines and protocols, including but not limited to: screening visitors, wearing PPE, posting signs reminding staff/residents/visitors about handwashing and how to recognize Covid symptoms, updating emergency contact information, training staff and ensuring resident personal rights.

LPA did not observe any deficiencies or health and safety concerns during this visit.


Report reviewed and delivered, exit interview conducted. A hard signed copy will be obtained via email and kept in the facility's file.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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