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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
191805246
Report Date:
06/29/2022
Date Signed:
06/29/2022 05:08:52 PM
Document Has Been Signed on
06/29/2022 05:08 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., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
BEL AIR GUEST HOME
FACILITY NUMBER:
191805246
ADMINISTRATOR:
SAMUEL, GALINA
FACILITY TYPE:
735
ADDRESS:
1440 NO. STANLEY AVENUE
TELEPHONE:
(323) 876-3370
CITY:
LOS ANGELES
STATE:
CA
ZIP CODE:
90046
CAPACITY:
64
CENSUS:
60
DATE:
06/29/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
01:18 PM
MET WITH:
Edgar Ramirez
TIME COMPLETED:
02:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced Case Management visit on 06/29/2022 at 1:18pm to address a self reported SOC341 received in the Woodland Hills South Regional Office on 06/27/2022. LPA met with Administrator Edgar Ramirez and explained the purpose of the visit.
LPA conducted a physical plant tour at 10:35am.
LPA requested and obtained copies of documents relevant to the investigation at 1:46pm. LPA interviewed the resident #2 (R2) at approximately 1:52pm. LPA spoke with the administrator on 06/24/2022 regarding the SIR received 06/24/2022.
Based on documents obtained LPA has determined that further investigation is required at this time.
Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME
:
Naira Margaryan
LICENSING EVALUATOR NAME
:
LaQueena Lacy
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/29/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/29/2022
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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