197607891-1-23-2024-31-AS-NRED-CZRNKH-20240123093158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607891
Report Date: 01/23/2024
Date Signed: 01/23/2024 09:32:06 AM

Document Has Been Signed on 01/23/2024 09:32 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CNS MARTHA		FACILITY NUMBER:	197607891
ADMINISTRATOR:	MARC SAINT CLAIR		FACILITY TYPE:	735
ADDRESS:	19443 MARTHA STREET		TELEPHONE:	(818) 342-9443
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY: 6		CENSUS: 6	DATE:	01/23/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Marc Saint Clair		TIME COMPLETED:	09:35 AM

NARRATIVE

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At 8:30 a.m. on 01/23/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the assistant administrator and later the administrator and disclosed the reason for the visit. LPA toured the facility at 9:15 a.m..

Today’s case management visit was conducted to issue a letter of immediate exclusion to Staff #1 (S1).

The letter was served to the administrator. S1 was not present at the facility during the time of this visit. The administrator notified LPA that S1 had not yet started employment at the facility and has never been present at the facility. Immediate exclusion letter sent via certified mail to S1’s home address on 12/19/2023.

No immediate health and safety hazards were observed during this visit.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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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