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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608400
Report Date: 08/04/2022
Date Signed: 08/04/2022 08:45:57 PM


Document Has Been Signed on 08/04/2022 08:45 PM - 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:COUNTRY HOME ALCOVE RESIDENTIAL CAREFACILITY NUMBER:
197608400
ADMINISTRATOR:MARIA D. PIPER/HELM SICATFACILITY TYPE:
740
ADDRESS:7645 ALCOVE AVENUETELEPHONE:
(818) 841-1115
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 0DATE:
08/04/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria D. PiperTIME COMPLETED:
10:30 AM
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On 08/04/2022, from 9:30 to 10:00 a.m., Licensing Program Analyst (LPA) Sandra Urena conducted a closure visit to verify that the facility is vacant. The LPA met with Administrator Maria D. Piper, and explained the reason for the visit.

The LPA, and the Administrator conducted a walk through of the facility, and the LPA was able to confirm that residents were not residing at the facility.


Exit interview was conducted, and a copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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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