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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601800
Report Date: 06/28/2023
Date Signed: 06/29/2023 08:33:04 AM


Document Has Been Signed on 06/29/2023 08:33 AM - 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: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: 3DATE:
06/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Bella MedallaTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required
annual inspection at 12:45 p.m. The LPA spoke with administrator Bella Medalla, and explained the reason for the visit. At time of arrival, the administrator stated that there are currently three residents admitted to the facility, however one is at the hospital.

The LPA and the administrator toured the physical plant areas inside and outside to ensure there are no
health and safety hazards and facility is in compliance with Title 22 Regulations.

Due to time constraints, LPA Urena will return on another date to complete the Annual inspection.

Exit interview was conducted with Administrator. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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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