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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850277
Report Date: 01/19/2024
Date Signed: 01/19/2024 04:59:10 PM


Document Has Been Signed on 01/19/2024 04:59 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:BENTLEY HILLSFACILITY NUMBER:
195850277
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:22740 HATTERAS STREETTELEPHONE:
(213) 478-0460
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 5DATE:
01/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Christian Havsgaard, ApplicantTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced case management visit at the above location. At 4:10 p.m., the LPA met with staff, Vanessa Barcela Haavsgard and applicant Christian Havsgaard, and explained the reason for the visit. At 4:49 p.m., the LPA spoke with Licensee representative, Stephany Perez over the telephone, and Stephany authorized applicant to sign the report.

The purpose of the visit is to ensure there are no health and safety hazards. Starting at 4:13 p.m., the LPA along with staff conducted a physical plant tour. The LPA observed the area near the back of the facility and noted it no longer had the unpermitted wall/ staff room. The LPA observed the former garage turned living area near the front of the facility to no longer have the blocked door, stove, and over the range hood. At 4:18 p.m., the LPA requested a copy of the resident roster.

No deficiencies issued at this time. 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: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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