197606920-7-8-2022-31-AS-MCAA-CG5NV6-20220708104726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606920
Report Date: 07/08/2022
Date Signed: 07/08/2022 10:47:34 AM

Document Has Been Signed on 07/08/2022 10:47 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:	RETZEL CARE HOME III		FACILITY NUMBER:	197606920
ADMINISTRATOR:	BLANCA D LOPEZ		FACILITY TYPE:	740
ADDRESS:	19825 LEADWELL STREET		TELEPHONE:	(818) 734-6988
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 3	DATE:	07/08/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Francisco Fabrigas, Camaron Gacayan		TIME COMPLETED:	11:00 AM

NARRATIVE

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Licensing Program Analyst (LPA) MIchael Cava conducted a Case Management visit due to the forfeiture of license of Retzel Home III that was scheduled for 04/16/2022. Initial closure date was set for 03/16/22, but the licensee had submitted a request for an extension, approved by the Department. LPA met with the current administrators, Francisco Fabrigas and Camaron Gacayan for the pending application under Home for the Elderly, and staff Matthew Calibara.

On 12/20/2021, LPA met with the licensee, 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 pertinent dates highlighted.

The Administrator provided proper notices and submitted resident roster (LIC9020-A) on 12/21/2021. The closure notice and Stipulation and Waiver and Order remain posted at the facility.

Since the most recent visit on 6/24/2022, the three remaining residents on the roster are still residing at the facility. Applicant submitted an application to CAB under Home for the Elderly. A pre licensing visit for the new operators was made on 6/10/2022, but until the application process is completed, facility will continue to operate under this license for Retzel Care Home III. LPA will continue to conduct case management visits every two weeks until Home for the Elderly becomes licensed. Staff and administrator advised.

No health and safety issues were noted during this visit.

LPA conducted exit interview and a copy of this report was issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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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