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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606522
Report Date: 06/15/2023
Date Signed: 06/15/2023 04:39:43 PM


Document Has Been Signed on 06/15/2023 04:39 PM - 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:ANDREA'S ELDERLY RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197606522
ADMINISTRATOR:ANDY M. AGUILANFACILITY TYPE:
740
ADDRESS:22901 CANTLAY STREETTELEPHONE:
(818) 914-4254
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 5DATE:
06/15/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:TIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced case management visit to the facility and met with Administrator, Elaine Bote.
LPA informed the Administrator that this visit was conducted to inspect the facility and to ensure that all residents' health and safety is protected while the facility is operating under the emergency circumstances due to death of the Licensee.

On 06/12/2023 Woodland Hills South Regional Office (WHS RO) was informed that the Licensee Andy M. Aguilan, passed away on 06/11/2023. On 06/13/2023 Licensees wife Reggie Aguilan arrived to WHS RO to sign the documents for an Emergency Approval to Operate (EAO) LIC9117. Proof of control of the property was also submitted to the RO. While operating under emergency circumstances, the Licensee’s wife is moving forward to transferring the ownership.

During this visit at 3:40PM LPA Alvizar inspected the facility inside and outside. Inspection included residents’ bedrooms, bathrooms, kitchen, and common areas. Facility had sufficient amount of perishable and non-perishable food supply.
At the time of this visit the physical plant appeared to be in substantial compliance with title 22 Regulations.
All residents residing in the facility were observed and assessed. They appear to be clean and well groomed sitting in living room reclining chairs watching television.

No immediate health and safety hazard were noted at the time of this visit.
Exit interview was conducted and a copy of report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
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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