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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609538
Report Date: 06/14/2022
Date Signed: 06/14/2022 04:08:14 PM


Document Has Been Signed on 06/14/2022 04:08 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., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ROSE VALLEY ALTADENA IFACILITY NUMBER:
197609538
ADMINISTRATOR:HSU, MICHAELFACILITY TYPE:
740
ADDRESS:2135 SANTA ANITA AVETELEPHONE:
(626) 375-8888
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 0DATE:
06/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Anna Iscoa, StaffTIME COMPLETED:
04:15 PM
NARRATIVE
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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 Staff, Anna Iscoa. The purpose of the visit was discussed..

At 2:40pm, LPA Valenzuela began a physical plant tour of the facility. LPA inspected the four (04) rooms. All four (06) rooms were vacant. There were no residents in any of the rooms.

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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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