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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606618
Report Date: 12/20/2021
Date Signed: 12/20/2021 04:27:14 PM

Document Has Been Signed on 12/20/2021 04:27 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:RETZEL CARE HOME IIFACILITY NUMBER:
197606618
ADMINISTRATOR:SANDRA BELLOFACILITY TYPE:
740
ADDRESS:9540 DONNA AVENUETELEPHONE:
(818) 960-4507
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
12/20/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Retzel FabregasTIME COMPLETED:
04:30 PM
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Licensing Program Analyst Abeye Duguma and Licensing Program Manager Eva Miller met with Licensee Retzel Fabregas to review the Stipulation and Waiver and Order which was adopted by the Department as its decision and ordered December 16, 2021. During the meeting, the Stipulation and Waiver and Order was read in its entirety with the following dates and details highlighted for common understanding and clarity;

Revocation of License
  • The stay shall be for ninety (90) days (12/16/2021 - 03/16/2022)
  • If Respondent requires an additional thirty (30) days in addition to the ninety (90) days referenced above, the Respondent must make the request in writing during the initial sixty (60) days of the stay (12/16/2021 - 02/14/2022)
  • In no case shall the total number of days of the ninety (90) day stay exceed one hundred-twenty (120) days (12/16/2021 - 04/15/2022)
  • Within twenty-four (24) hours of the date that the Respondent receives the Order adopting the Stipulation, Respondent shall give a sixty (60) day written notice to each client and client's responsible party that Respondent may no longer provide care and supervision after the closure date and that all clients who require care and supervision will be required to relocate if Respondent is unable to complete a sale or transfer of the facility. Respondent shall submit a copy to the Department at its licensing office.
  • Respondent shall forward to the Department a list of all clients who have been served with the notice to relocate, as well as the name, address and telephone number of the place to which each client will be located.
  • Respondent shall NOT accept any new clients at the facility.

(CONT on LIC 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RETZEL CARE HOME II
FACILITY NUMBER: 197606618
VISIT DATE: 12/20/2021
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Revocation of Administrator Certificate
  • Respondent's administrator certificate shall be revoked for a period of two (02) years from the effective date of the Order adopting this Stipulation (12/16/2021 - 12/16/2023).
  • Respondent is excluded from being a licensee, owning a beneficial ownership interest of ten (10) percent or more in a licensed facility, or being an administrator, officer, director, member, or manager of a licensee or entity controlling licensee, and, further, from employment and presence in a licensed facility and from having contact with clients of a facility licensed by the Department, holding the position of member of a board of directors, executive director, or officer of a licensee of any facility licensed by Department, for a period of two (2) years from the effective date of the Order adopting this Stipulation (12/16/2021 - 12/16/2023), with the exception that Respondent is permitted to be employed at, have presence in, and contact with clients of, the facility during the stay of the license revocation as previously specified.

Licensee reported five (05) residents under hospice care at Retzel Care Home II. Licensee will submit proof of written notice to residents and responsible party within 24 hours as well as a list of residents who have received said notification.

This meeting and/or document in no way replaces or supplements any oral or written agreements, proceedings, adoptions, understandings, or otherwise, between the Department and the Respondent.

A copy of this report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC809 (FAS) - (06/04)
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