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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608218
Report Date: 12/24/2021
Date Signed: 12/24/2021 10:13:07 AM

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:ELYSIUM RESIDENTIAL CAREFACILITY NUMBER:
197608218
ADMINISTRATOR:JENNETH AGUILARFACILITY TYPE:
740
ADDRESS:11436 OSTORM AVENUETELEPHONE:
(818) 620-2202
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
12/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jenneth Aguilar/ AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct an infection control/ required annual. LPA had his temperature checked and given a COVID-19 questionnaire before being allowed entry.

The facility is currently following all COVID -19 protocols and following their mitigation plan. A brief tour of the physical plant was also conducted and no health and safety concerns were observed during the visit. The smoke alarms and carbon monoxide detectors were tested and functioned properly.

No health and safety issues were observed during todays visit.

Exit interview conducted and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2021
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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