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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609112
Report Date: 11/19/2024
Date Signed: 11/19/2024 04:09:12 PM

Document Has Been Signed on 11/19/2024 04:09 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AV RESIDENTIAL IIIFACILITY NUMBER:
197609112
ADMINISTRATOR/
DIRECTOR:		DAWSON, KRISTIFACILITY TYPE:
735
ADDRESS:1160 WEST AVE J5TELEPHONE:
(661) 941-8175
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
11/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Linda FairbanksTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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On 11/19/224, at 9:30am Licensing Program Analysts (LPAs) Gina Saucedo and Angelica Segovia conducted an unannounced visit at this facility to close the facility and cease operation. Upon entry of the facility, LPA's observed two (2) residents and a caregiver present. The caregivers name was Linda Fairbanks.

LPA's conducted a physical plant and observed two (2) residents in one (1) room. The other two (2) rooms were empty and one (1) room is the occupied by the caregiver. There are two (2) bathrooms in this single-story home with a backyard. There is no bodies of water.


Let it be noted, facility was not closed due to clients/residents still being housed at the above facility. This is the second attempt to close this facility.

Copy of the report will be sent to the licensee/administrator via email.
Troy AgardTELEPHONE: (818) 596-4334
Gina SaucedoTELEPHONE: (818) 304-3057
DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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