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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:57:00 PM


Document Has Been Signed on 12/20/2023 04:57 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:TREVIN R WILLISFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:60CENSUS: 49DATE:
12/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:43 PM
MET WITH:Trevin WillisTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 3:43 p.m., the LPA met with Administrator, Trevin Wills and explained the reason for the visit.

The reason for today's inspection is to follow up on two (2) self-reported Report of Suspected Dependent Adult/Elder Abuse (SOC 341), one submitted on 12/18/2023 and the other submitted on 12/20/2023. At 3:45 p.m., the LPA conducted an interview with the Administrator. At 4:03 p.m., the LPA obtained copies of pertinent documents. At 4:42 p.m., the LPA along with the Administrator conducted a physical plant tour.

No immediate health and safety concerns were observed during today's inspection.

Further investigation is required at this time. An additional reports may follow if warranted.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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