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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609782
Report Date: 05/03/2022
Date Signed: 05/04/2022 08:49:00 AM


Document Has Been Signed on 05/04/2022 08:49 AM - 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: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: 6DATE:
05/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Carrie AcostaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required
annual visit at 1:00 p.m. This annual had an emphasis on infection control practices and procedures. The
LPA spoke with administrator, and explained the reason for the visit.

The LPA and the administrator toured the physical plant areas inside and outside to ensure there are no
health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The residents’ bedrooms were furnished appropriately with clean linens, appropriate
furnishings and sufficient lighting.

RESTROOMS: Restrooms are clean, sanitary and in operating condition. The common bathrooms were observed with appropriate signs and stocked with paper towels. Hand washing signs were posted in the common and private bathrooms.

COMMON SPACES: At the time of the visit, furniture, walls, and flooring were observed to be in good condition. The LPA observed the required postings on the wall in the dinning roomy. The LPA observed sanitizer interspersed throughout the facility.

Backyard: The backyard has a patio area with sitting furniture and umbrella for residents and family members to meet.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782
VISIT DATE: 05/03/2022
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INFECTION CONTROL: During today’s visit, the LPA spoke with staff and the Licensee Representative
regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station.

No deficiencies cited at this time. Exit interview conducted. Signatures obtained. The report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
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