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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608694
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:29:05 PM

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:VILLAGE AT SHERMAN OAKS, THEFACILITY NUMBER:
197608694
ADMINISTRATOR:PAMELA MUNDAYFACILITY TYPE:
740
ADDRESS:5450 VESPER AVETELEPHONE:
(818) 994-7900
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY:100CENSUS: 67DATE:
11/04/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Yazmin Hernandez - Enliven DirectorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management visit in regard to a self reported incident that occurred on October 26, 2021. On that date Resident 1 (R1) was sitting and yelling inside of the dining room when Staff (S1) screamed at resident to "Shut up".

Between 02:00pm – 03:30pm, LPA conducted a physical plant, reviewed and obtained copies of documents pertinent to the incident and interviewed staff.

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

Further review required prior to LPA concluding the investigation for the incident received on 10/26/2021.



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: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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