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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608549
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:04:44 PM


Document Has Been Signed on 01/25/2024 02:04 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:GLENDALE CAREHOMEFACILITY NUMBER:
197608549
ADMINISTRATOR:EVANGELINE URSUAFACILITY TYPE:
740
ADDRESS:714 MILFORD STREETTELEPHONE:
(818) 640-2912
CITY:GLENDALESTATE: CAZIP CODE:
91203
CAPACITY:6CENSUS: 0DATE:
01/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Antonio Ining, Facility RepresentativeTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced case management visit to the facility to ensure that there are no residents in care. LPA met with Antonio Ining, facility representative. The purpose of the visit was discussed with the licensee.

At 1:30pm, LPA Valenzuela began a physical plant tour of the facility. LPA inspected the three (03) rooms were residents in care resided. All three (03) rooms were vacant. There were no residents in any of the rooms. LPA looked inside the closets and checked all drawers and saw no personal belongings or clothes inside.

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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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