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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609986
Report Date: 10/13/2022
Date Signed: 10/14/2022 03:57:23 PM


Document Has Been Signed on 10/14/2022 03:57 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:ARBOR GROVE CAREFACILITY NUMBER:
197609986
ADMINISTRATOR:DOLMAN, ANDREWFACILITY TYPE:
740
ADDRESS:14819 VALERIO STREETTELEPHONE:
(818) 809-2594
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 0DATE:
10/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Andrew DolmanTIME COMPLETED:
09:36 AM
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On 10/12/2022, Licensing Program Analyst (LPA) Sandra Urena spoke with Administrator Andrew Dolman on the phone to inform him for the reason of the visit. A walk-through of the facility has to be conducted to ensure that all residents have been relocated before the Community Care Licensing Division (CCLD) office can declare the facility closed. Mr. Dolman stated that all residents were relocated, that the lease of the property ended, and the facility is now closed. LPA Urena stated to the administrator that a visit would still be conducted on 12/13/2022. The LPA informed the administrator that a copy of the report would be emailed after the visit.

On April 21, 2022, LPA Walker received a telephone call from Administrator Andrew Dolman to inform CCLD of the facility's intent to Close the facility by 09/01/2022.

On 10/13/2022, LPA Urena conducted a visit to the facility. Upon arrival at the facility, the LPA noticed construction workers working in the facility. The LPA entered the facility and found it to be under construction, and no residents were living at the facility at this time.


A copy of the report LIC 809 was emailed to the administrator for his signature, and to be returned to LPA Urena upon signing the report.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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