Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191805246
Report Date: 01/27/2020
Date Signed: 01/27/2020 01:01:14 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:BEL AIR GUEST HOMEFACILITY NUMBER:
191805246
ADMINISTRATOR:SAMUEL, GALINAFACILITY TYPE:
735
ADDRESS:1440 NO. STANLEY AVENUETELEPHONE:
(323) 876-3370
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:0CENSUS: 62DATE:
01/27/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Edgar Ramirez - Assistant AdminsitratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) conducted an unannounced case management visit for the incident report that was received from the facility on 01/22/2020. Upon arrival LPA was met by Assistant Administrator Edgar Ramirez and explained the reason for the visit.

An incident report received on 01/22/2020 informed Licensing that Resident 1 (R1) left the facility and has yet to return.

LPA conducted physical plant, interviewed staff, reviewed facility files and obtained copies of documents pertinent to this incident.

Administrator stated they had filed a police report and they have not provided any updates at this time. According to the Administrator, R1 typically leaves the facility during the day and returns in the evening. Administrator is unaware what R1 does while they're not in the facility. Administrator also stated the responsible party for R1 said that they have not been able to get a hold of R1 during this time as well.

There was no health and safety hazard observed during this visit and Administrator will update LPA as soon as they get new information.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Alex EstradaTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2020
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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