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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197603834
Report Date:
09/30/2020
Date Signed:
09/30/2020 04:09:25 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., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
SENIOR HAVEN
FACILITY NUMBER:
197603834
ADMINISTRATOR:
TERESITA ALVAREZ
FACILITY TYPE:
740
ADDRESS:
7633 SHOUP AVE
TELEPHONE:
(818) 992-5703
CITY:
WEST HILLS
STATE:
CA
ZIP CODE:
91304
CAPACITY:
6
CENSUS:
0
DATE:
09/30/2020
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:30 PM
MET WITH:
Teresita Alvarez.
TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted a virtual closure visit via Face-time with administrator/licensee Teresita Alvarez. Visit was conducted virtually do to the Covid-19 pandemic.
LPA was given a physical plant tour of the facility. LPA observed the facility to be empty of residents and that all resident belongings were moved out. LPA received the information to what location each resident has been relocated to. LPA sent administrator an email with the link to the closure survey. Administrator stated she would complete the survey by the end of today. Exit Interview conducted. Copy of report emailed. Signature on hard copy.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
09/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/30/2020
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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