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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
191805246
Report Date:
09/30/2021
Date Signed:
10/08/2021 09:03:41 AM
Document Has Been Signed on
10/08/2021 09:03 AM
- 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:
63
DATE:
09/30/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
Galina Samuel
TIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPAs) LaQueena Lacy and Abeye Duguma conducted an unannounced case management visit to deliver the finding for LPA Naira Margaryan compliant report control number 31-AS-20210510143548 dated 05/10/2021 and to follow-up on an unusual incident/injury/death report dated 08/02/21 that was received by Community Care Licensing (CCL). LPAs conducted a physical plant tour at 10:16am. At approxitmately 11:00am LPAs requested documents relevant to the investigation.
LPAs interviewed administrator and assistant administrator at 11:45am.
LPA has determined that additional time is required to review the documents obtained as well to obtain the coroner's report.
Based on the interviews and the document obtained LPAs have determined that further investigation is needed.
SUPERVISORS NAME
:
Naira Margaryan
LICENSING EVALUATOR NAME
:
LaQueena Lacy
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/30/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/30/2021
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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