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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197605258
Report Date:
01/07/2024
Date Signed:
03/19/2024 10:28:04 AM
Document Has Been Signed on
03/19/2024 10:28 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:
JENNIFER HOME
FACILITY NUMBER:
197605258
ADMINISTRATOR:
MARY JANE RAFANAN
FACILITY TYPE:
740
ADDRESS:
24401 JENNIFER PLACE
TELEPHONE:
(661) 254-7476
CITY:
NEWHALL
STATE:
CA
ZIP CODE:
91321
CAPACITY:
6
CENSUS:
5
DATE:
01/07/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Staff
TIME COMPLETED:
01:16 PM
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LPA attempted to conduct a 1 year required visit at this facility but staff informed the LPA that both them (staff) and residents are Covid positive.
SUPERVISOR'S NAME:
Troy Agard
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Jose Gary Tan
TELEPHONE:
(323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE:
01/07/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/07/2024
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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