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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609878
Report Date: 09/09/2022
Date Signed: 09/09/2022 12:57:12 PM


Document Has Been Signed on 09/09/2022 12:57 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:FELLI'S ASSISTED LIVINGFACILITY NUMBER:
197609878
ADMINISTRATOR:CORPUZ, NOEMIFACILITY TYPE:
740
ADDRESS:12322 LULL STREETTELEPHONE:
(805) 427-6232
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 0DATE:
09/09/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Noemi CorpuzTIME COMPLETED:
12:46 PM
NARRATIVE
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On 09/09/2022, at 12:05 p.m., Licensing Program Analyst (LPA) Sandra Urena conducted a closure visit to verify that the facility is vacant. The LPA met with Administrator Noemi Corpuz, who stated via an email submitted on 09/09/2022 that they are closing the facility at this time due to inability to acquire clients for the facility.

The LPA, and the Administrator conducted a walk through of the facility from 12:10 p.m. to .12:20 p.m., and the LPA was able to confirm that there were no residents residing at the facility. Per the administrator, the facility never had residents living at this location. The administrator stated that a friend is currently staying at this location.

On 10/11/2022, the licensee was advised of the following: Licensee did not pay initial Annual fee due on 08/05/2020 for $495. Late fees accrued on 10/15/2020 for $247. Licensee did not pay annual fees due on 08/04/2021 for $495. Late fees accrued on 10/01/2021 for $247. Licensee's annual fees are past due at this time. The total due including late charges is $1,484. The Administrator was advised of annual fees not being up to date via telephone by Licensing Program Manager (LPM) Jeralyn Pfannenstiel prior to 10/11/2021.

Annual Fees were discussed during today’s visit. Facility's annual fees are past due at this time, and as of
09/09/2022, the total due fees, including late charges are $1,979 dollars.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report and Appeal Rights were issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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Document Has Been Signed on 09/09/2022 12:57 PM - It Cannot Be Edited

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: FELLI'S ASSISTED LIVING
FACILITY NUMBER: 197609878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited

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87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
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Based on LPA observation, and facility record review, the licensee did not comply with the section cited above, as the licensee failed to ensure the facility annual fees were paid from 2020 through 2022, , which poses a potential health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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