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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608478
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:33:35 PM


Document Has Been Signed on 07/21/2022 02:33 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:SUNRISE ASSISTED LIVING OF WOODLAND HILLSFACILITY NUMBER:
197608478
ADMINISTRATOR:BENITO DEL TOROFACILITY TYPE:
740
ADDRESS:20461 VENTURA BLVDTELEPHONE:
(818) 346-9046
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:127CENSUS: 71DATE:
07/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Patrice O' Grady - Executive DirectorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case management - Incident inspection pertaining to a self reported SOC 341 received on 7/20/2022. LPA met with Executive Director Patrice O' Grady and explained the reason for the visit.

The self reported SOC 341 pertains to an incident that occurred on 7/10/2022 where it was reported that Staff 1 (S1) made a derogatory  statement towards  Resident 1 (R1). At approximately 10:00am, LPA conducted physical plant, interviewed staff and residents as well as reviewed and obtained copies of pertinent documents relevant to the incident. Further investigation is required 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: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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