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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608023
Report Date: 09/28/2023
Date Signed: 09/28/2023 08:44:32 AM

Document Has Been Signed on 09/28/2023 08:44 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:SUNGATE CARE FACILITYFACILITY NUMBER:
197608023
ADMINISTRATOR:TASHA KANALEYFACILITY TYPE:
735
ADDRESS:3441 SUNGATE DR.TELEPHONE:
(661) 526-7848
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
09/28/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Dolly BarrazaTIME COMPLETED:
08:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth and Licensing Program Analyst Lorena Casillas conducted a collateral visit at the facility and was greeted by the caregiver.

LPA Spaeth stated the purpose of the visit was to interview a client (C1), LPAs interviewed client at 8:05 am until 8:12 am.

LPAs also interviewed two caregivers (S1 and S2) at 8:15 am until 8:35 am.

Exit interview conducted and copy of report left for the facility.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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