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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609871
Report Date: 01/24/2024
Date Signed: 01/24/2024 01:42:28 PM


Document Has Been Signed on 01/24/2024 01:42 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:HEPZEBAH HOUSEFACILITY NUMBER:
197609871
ADMINISTRATOR:JACKSON, SYLVIAFACILITY TYPE:
740
ADDRESS:22230 VANOWEN STTELEPHONE:
(310) 213-4927
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91303
CAPACITY:6CENSUS: 4DATE:
01/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sylvia Jackson administratorTIME COMPLETED:
01:00 PM
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At 09:30am, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina conducted an unannounced Case Management Visit. The team met with the Administrator Sylvia Jackson and explained the reason for the visit.

The purpose of todays visit is to review all residents and staff files for an accuracy. Team was informed that the facility currently has five (4) residents. Facility also has three (2) staff members, but during today's visit the team observed one staff member (S1) on duty. The team checked the Licensing Information System (LIC) and observed that (S1) is associated with this facility and the fingerprints are cleared.

Resident Files: At 9:40am team conducted resident and staff records review. The following was observed. Four (4) out of four (4) resident facility files had all required documents.

Staff Files: Administrator stated that the facility currently has four (2) staff members. All required documents and trainings are on file.

No deficiencies are issued during today’s visit.


Exit interviewed conducted and copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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