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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197607284
Report Date:
02/04/2022
Date Signed:
02/14/2022 12:36:21 PM
Document Has Been Signed on
02/14/2022 12:36 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:
LIFESTYLE HOME CARE FOR SENIORS
FACILITY NUMBER:
197607284
ADMINISTRATOR:
BIENVENIDA B. GOUDEAUX
FACILITY TYPE:
740
ADDRESS:
11734 DORAL AVENUE
TELEPHONE:
(818) 368-5108
CITY:
NORTHRIDGE
STATE:
CA
ZIP CODE:
91326
CAPACITY:
4
CENSUS:
0
DATE:
02/04/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:30 PM
MET WITH:
Bienvenida Goudeaux, Administrator
TIME COMPLETED:
04:25 PM
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LPA Tihesha "Lynn" Smith made an unannounced Case Management visit to this facility to ensure that it is no longer in operation as administrator revealed on 01/24/2022 during prior visit she will be closing the facility. LPA met the Administrator and explained the purpose of this visit. LPA toured the facility and observed no sign of elder clients or care being provided for the elderly. Administrator surrendered license to LPA.
Based on today’s visit this facility will be officially closed as of 01/24/2022.
Copy emailed.
SUPERVISOR'S NAME:
Naira Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Tihesha Smith
TELEPHONE:
818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE:
02/04/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/04/2022
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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