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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607891
Report Date: 05/03/2022
Date Signed: 05/03/2022 10:46:50 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/03/2022 10:46 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:CNS MARTHAFACILITY NUMBER:
197607891
ADMINISTRATOR:CLABAUGH, MARCFACILITY TYPE:
735
ADDRESS:19443 MARTHA STREETTELEPHONE:
(818) 342-9443
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 0DATE:
05/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:CesarTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Michael Cava attempted to conduct a required infection control annual at this facility. At arrival, LPA met with a contractor named Cesar, who advised the LPA that facility has ceased operation temporarily due to repairs. Cesar stated the facility has been under construction for a couple of months now and there is nobody living or overseeing operation at the home. It is vacant due to the construction. No resident or staff occupancy. Cesar stated work is being done to the floors and walls due to some flooding and mold.

Prior to this inspection, LPA did a file review and did not see that CCL received notification that the facility has ceased operation at this time for repairs. LPA will attempt to contact the licensee via telephone and email. A copy of this report will be emailed to the licensee at the email address provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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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