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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607236
Report Date: 10/26/2022
Date Signed: 10/27/2022 08:02:16 AM


Document Has Been Signed on 10/27/2022 08:02 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:NINA'S ANGEL CARE HOMES, INC.FACILITY NUMBER:
197607236
ADMINISTRATOR:NINA WILLIAMSFACILITY TYPE:
740
ADDRESS:17409 1/2 KINGSBURY STREETTELEPHONE:
(818) 370-7629
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:4CENSUS: 0DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nina WilliamsTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA),Patrick Shanahan, arrived at the facility in order to conduct an annual inspection. The LPA was greeted by the facility administrator. The inspection tool was used to conduct the annual.

The administrator explained that she has not had a resident in over 1 year. The administrator expressed her wish to close the facility due to recent health issues. A physical plant walk through was conducted and no residents were observed. The administrator did have PPE available.

Exit interview conducted and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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