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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609782
Report Date: 06/11/2021
Date Signed: 06/11/2021 12:00:15 PM

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:CARRIES CARE VILLAFACILITY NUMBER:
197609782
ADMINISTRATOR:ACOSTA, MARK RYANFACILITY TYPE:
740
ADDRESS:12550 BURTON STTELEPHONE:
(818) 767-4503
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 4DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Carrie AcostaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA’) Sandra Urena and Emily Peraldi conducted an unannounced Required -1 Year inspection. LPAs met with Administrator Carrie Acosta. Census on this day was four residents.

LPAs conducted a facility tour to inspect for infection control practices. Infection control practices were in place, temperatures were taken, signing book for visitors was present and Infection Control posters were displayed throughout the facility. Perishable and non-perishable supplies met the required regulations. There was a variety of foods available for different meals. An inspection of the common area, resident’s rooms and restrooms were conducted. The bedrooms were clean, airy and bright. Restrooms had hand washing signs displayed. Outdoor area had ramps in good condition for accessibility and exiting of rooms.

A large supply of PPE was observed in the garage area. LPAs checked the fire extinguisher; it was up to date on service.

No citations were issued during today's visit.

Exit interview conducted, today's report was reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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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