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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850180
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:34:14 PM


Document Has Been Signed on 03/23/2022 01:34 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:COTTAGES AT THE COLONY OF SHERMAN OAKS #3FACILITY NUMBER:
195850180
ADMINISTRATOR:LEVENTER, DVORAFACILITY TYPE:
740
ADDRESS:5426 TYRONE AVENUETELEPHONE:
(818) 479-3700
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 6DATE:
03/23/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dvora Leventer, AdministratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived unannounced for a Collateral visit. At 12:30 p.m., the LPA met with Administrators and explained the reason for the visit.

Today's inspection is in regard to the investigation of complaint control 29-AS-20200522114447 which is unrelated to this facility.

No health and safety concerns were observed during this visit. Exit interview conducted. Current Administrator refused to sign the report and the copy of the report will be mailed to the Licensee.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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