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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601800
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:40:54 PM

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:MEDAL RESIDENTIAL BOARDING & CAREFACILITY NUMBER:
197601800
ADMINISTRATOR:BELLA MEDALLAFACILITY TYPE:
740
ADDRESS:12952 ELKWOOD STREETTELEPHONE:
(818) 503-3980
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 0DATE:
10/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bella MedallaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management visit to obtain additional information pertaining to complaint control # 29-AS-20210415084328

Between 11:30am - 2pm, LPA conducted physical plant and reviewed and obtained copies of pertinent documents related to complaint investigation above.

No deficiencies issued at this time. Exit interview conducted and report issued and sent via email. .
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing 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.
LIC809 (FAS) - (06/04)
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