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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609362
Report Date: 08/04/2021
Date Signed: 08/04/2021 01:32:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HEIGHTS AT BURBANK, THEFACILITY NUMBER:
197609362
ADMINISTRATOR:DAWN SMITHFACILITY TYPE:
740
ADDRESS:2721 WILLOW STREETTELEPHONE:
(818) 954-9500
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:130CENSUS: 78DATE:
08/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Dawn Smith, Executive DirectorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit for the purpose of serving an Immediate Exclusion letter for Staff #1.

LPA met with Executive Director, Dawn Smith, and hand delivered the Immediate Exclusion letter.

A copy of this report was provided to the Executive Director.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
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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