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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609990
Report Date: 05/29/2020
Date Signed: 05/29/2020 03:19:52 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:AMENA LOVE BOARD AND CAREFACILITY NUMBER:
197609990
ADMINISTRATOR:JONES, MERCERFACILITY TYPE:
740
ADDRESS:10751 VIKING AVETELEPHONE:
(747) 239-3247
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY:6CENSUS: 4DATE:
05/29/2020
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Mercer JonesTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness, conducted a COMP III interview and orientation with Administrator Mercer Jones. All information was provided to Administrator, and exit interview was conducted.

LPA will obtain signature via email.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2020
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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