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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609745
Report Date: 02/28/2022
Date Signed: 02/28/2022 04:43:27 PM

Document Has Been Signed on 02/28/2022 04:43 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:GROWTH EXTENDED INCFACILITY NUMBER:
197609745
ADMINISTRATOR:LEWIS, JOYFACILITY TYPE:
772
ADDRESS:15743 COVELLO STTELEPHONE:
(888) 549-8884
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 0DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Balisi attempted to conduct a required annual visit to the facility. LPA knocked on the door and there was no answer. LPA called the licensee, who informed LPA the facility had no clients and the licensees were out of town. LPA asked licensee to notify CCL when they have clients and LPA will continue the annual at another time.

Exit interview, report emailed to licensee for signature
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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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