<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609877
Report Date: 09/29/2021
Date Signed: 09/29/2021 01:32:51 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:IN HOME CARE CENTERFACILITY NUMBER:
197609877
ADMINISTRATOR:DOVLATYAN, KRISTINEFACILITY TYPE:
740
ADDRESS:9023 GAVIOTA AVETELEPHONE:
(747) 998-7577
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Alice Sargsyan TIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in order to re-issue a report.


On 8/10/21 LPA conducted an unannounced annual/ COVID Mitigation visit to the facility. The Infection Control domain of the Residential Care For the Elderly (RCFE) inspection tool was utilized to inspect the facility and ensure that it is following its approved Covid Mitigation Plan.

No deficiencies were observed at the time of the 8/10/21 visit nor during a phyical plant tour on 9/29/21.

Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1