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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 09/28/2021
Date Signed: 09/28/2021 11:15:55 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:FOUR SEASONS ASSISTED LIVING CENTER LLCFACILITY NUMBER:
197608280
ADMINISTRATOR:MELISSA CHRISTOPHERFACILITY TYPE:
740
ADDRESS:12120 CHANDLER BLVDTELEPHONE:
(818) 487-0770
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91607
CAPACITY:49CENSUS: 30DATE:
09/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melissa Christopher - Administrator TIME COMPLETED:
11:00 AM
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Licensing Program Analyst conducted an unannounced case management visit to conduct additional interviews related to complaint # 29-AS-20200810165320. Between 9am - 11am, LPA also reviewed and obtained copies of pertinent documents relevant to the investigation.

LPA did not observe and immediate or potential health and safety concerns at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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