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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700721
Report Date: 10/12/2021
Date Signed: 11/08/2021 10:04:54 AM

Document Has Been Signed on 11/08/2021 10:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:CARE TO STAY HOMEFACILITY NUMBER:
194700721
ADMINISTRATOR:KOONTZ, BRIANFACILITY TYPE:
300
ADDRESS:3900 W ALMEDA AVE STE1200TELEPHONE:
(818) 446-6966
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 0CENSUS: DATE:
10/12/2021
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Brian KoontzTIME COMPLETED:
10:15 AM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Care To Stay Home on 10/12/2021. Upon arrival, the HCSB analyst identified himself and was greeted by Brian Koontz. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with Brian Koontz and informed him that no discrepancies were found.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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