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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609816
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:07:30 PM


Document Has Been Signed on 10/16/2024 01:07 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:STANSBURY PLACE INCFACILITY NUMBER:
197609816
ADMINISTRATOR:SHINN, MARIA ELENAFACILITY TYPE:
740
ADDRESS:8425 STANSBURY AVETELEPHONE:
(818) 924-7165
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:5CENSUS: 5DATE:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Joshua SmithTIME COMPLETED:
01:16 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management - Incident visit to follow up on a LIC 624 Incident report received by the department on 10/15/2024.The LPA met with Licensee Joshua Smith, Administrator Maria Shinn, and staff Marie Neri, and explained the reason for the visit.

On 10/15/2024, the department reviewed a Special Incident Report (LIC 624) for Resident #1 (R1) sent by facility staff. The report indicated that on 10/13/2024, at 8:10 p.m. staff (S1) noticed that R1 had eloped the facility. Facility staff contacted R1’s next of kin to inform them of the incident and contacted law enforcement to file a missing person report.

At approximately 10:15 a.m., LPA Urena conducted a physical plant tour, interviewed staff, and R1’s next of kin as well as reviewed and obtained pertinent documents relevant to the investigation. R1 was still missing at the time of the visit. R1’s next of kin is working with law enforcement, missing person’s department to get the case out to the media and public to ask for assistance to locate R1. LPA did not observe any immediate or potential health and safety concerns at this time.

The LPA has determined further investigation is needed and will return at a later date to complete the investigation if warranted.

Exit interview conducted and copy of report issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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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