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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607384
Report Date: 02/24/2024
Date Signed: 02/24/2024 01:38:54 PM


Document Has Been Signed on 02/24/2024 01:38 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:CASA COSTELLOFACILITY NUMBER:
197607384
ADMINISTRATOR:MARIA ELENA SHINNFACILITY TYPE:
740
ADDRESS:8347 COSTELLO AVE.TELEPHONE:
(818) 892-8853
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:4CENSUS: 4DATE:
02/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria Shinn, Licensee TIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 11:30 a.m., the LPA met with the Licensee, Maria Shinn and explained the reason for the visit. The facility is vendored by North Los Angeles Regional Center as a level three (3) home.

Starting at 11:41 a.m., the LPA conducted interviews with four residents (4) and one (1) staff. At 12:00 p.m., staff and two (2) residents returned from their outing.

RECORD REVIEWS: Between 11:46 a.m. and 12:45 p.m., the LPA conducted a file review for all staff regularly scheduled and observed the following: personnel records, health assessments, criminal record clearances, first aid/CPR and the appropriate training. All personnel files were in order. The Administrator’s certificate for Maria Shinn is active and expires on 08/06/2024. The LPA also reviewed and obtained copies of the following: surety bond, valid liability insurance, Infection Control Plan and Emergency and Disaster Plan. The most recent emergency disaster drill was conducted on 01/02/2024.

At 1:05 p.m., the LPA, along with staff, conducted a brief physical plant tour inside and outside to ensure there are no health and safety hazards.

Due to time constraints the LPA will return to complete the annual at a later date.

No deficiencies were observed at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2024
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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