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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197606348
Report Date:
01/07/2022
Date Signed:
01/07/2022 10:18:56 AM
Document Has Been Signed on
01/07/2022 10:18 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., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
COMMUNITY INTEGRATION ADC
FACILITY NUMBER:
197606348
ADMINISTRATOR:
PETER MEDVEDEV
FACILITY TYPE:
775
ADDRESS:
10100 BALBOA BL.
TELEPHONE:
(818) 772-1155
CITY:
GRANADA HILLS
STATE:
CA
ZIP CODE:
91343
CAPACITY:
120
CENSUS:
DATE:
01/07/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
TIME COMPLETED:
10:17 AM
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LPA arrived at the facility and spoke with CEO Peter Medvedev and COO Bob Erio. They stated that the day program was currently not providing any in-person services due to COVID-19.
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Alexander Pitz
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/07/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/07/2022
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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