<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601859
Report Date: 11/27/2023
Date Signed: 11/27/2023 10:32:12 AM


Document Has Been Signed on 11/27/2023 10:32 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:PALMDALE COURT CARE HOMEFACILITY NUMBER:
197601859
ADMINISTRATOR:EMMA RUTH C. ARANDAFACILITY TYPE:
740
ADDRESS:37656 SIMI STREETTELEPHONE:
(661) 285-0021
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY:6CENSUS: 0DATE:
11/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:EMMA RUTH C. ARANDATIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit. LPA Spaeth stated the purpose of this visit is to confirm and document the closure of this facility and ensure all residents have been relocated.

The facility closure was initiated by the licensee. The licensee notified Community Care Licensing Division (CCLD) on 9/01/2023 via letter stating the licensee intends to close the facility on 9/30/2023. The LPA received notification via phone call on November 14, 2023 from the Licensee stating the resident moved out as of 9/30/2023 and was relocated to another licensed facility. The Licensee stated to LPA that the facility has been closed. .

The Licensee and LPA Spaeth began the tour at 10:00 am until 10:08 am. LPA Spaeth observed there were no residents within the four resident bedrooms.

LPA Spaeth received the facility license from the Licensee. A copy of the signed report was given to the Licensee.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1