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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608807
Report Date: 07/26/2022
Date Signed: 07/26/2022 03:09:50 PM

Document Has Been Signed on 07/26/2022 03:09 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:CNS DOLOROSAFACILITY NUMBER:
197608807
ADMINISTRATOR:MARC SAINT CLAIRFACILITY TYPE:
735
ADDRESS:22341 DOLOROSA STREETTELEPHONE:
(818) 574-5312
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 4DATE:
07/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Director-Marc Saint ClairTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Elsie Campos made an unannounced site visit to the facility for the purpose of following up on a confirmation of removal notification for one person. LPA met with Director Marc Saint Clair and explained the reason for the visit.

A Decision and Order regarding Staff #1 (S1)'s exclusion from the facility was effective 7/7/2022. Documents were served to S1 and the Licensee on 7/7/2022. During today's visit, the LPA spoke with Marc Saint Clair pertaining to S1. During this visit, the LPA obtained a staff roster and a resident roster. Marc Saint Clair confirmed that S1 was hired and began on 7/12/21. S1 was last contacted on 8/20/2021 regarding S1’s schedule however, the facility did not hear from S1 again and determined S1 was a no call no show. Director Marc Saint Clair provided termination documentation that verifies that S1 was terminated effective 8/30/2021 and was also separated from the facility on Guardian effective 8/30/2021.

Based on the evidence obtained during today's visit, the LPA has verified that the individuals are not present, employed, or residing at the facility.

Verification of removal is complete. No deficiencies cited.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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