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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609996
Report Date: 08/12/2020
Date Signed: 08/12/2020 10:38:09 AM

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:A CARING VILLAFACILITY NUMBER:
197609996
ADMINISTRATOR:CABANBAN, LILIAFACILITY TYPE:
740
ADDRESS:25421 VIA GRACIOSOTELEPHONE:
(661) 254-6666
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 2DATE:
08/12/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Administrator/ Lilia CabanabanTIME COMPLETED:
11:00 AM
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Due to the Covid -19 pandemic, this pre-licensing was conducted via video phone. No signature digital signature was attained and a copy of the report was emailed to the administrator. A "wet" signature is on file in the main facility folder.
Component III was also conducted on todays visit.

A pre licensing visit was conducted by Licensing Program Analyst (LPA), Patrick Shanahan. The LPA met with administrator Lilia Cabanaban. This is a new Change of Ownership application. A dementia plan of operation was submitted.
LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. First-aid kit is complete; facility has adequate linen, perishable and nonperishable food supplies. Hot water measured at 117.8 degrees Fahrenheit. There is no swimming pool or other body of water present. Facility has working alarms on all exits. The backyard is completely fenced and gated with self-latching mechanisms. There is patio area backyard with table and chairs for resident use. All chemicals and sharps are in locked cabinets and drawers. Facility has 2 bathrooms; resident bathrooms have required grab bars installed. Fire Clearance is approved for 2 non-ambulatory and 4 bedridden. There are 3 shared rooms and 1 staff room. The washer and dryer are located in the garage.
Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Unit (CAU). You will be notified by the CAU Analyst when your license has been approved.
You are not allowed to begin operating until you have been notified that your license has been approved by the CAU Analyst. Failure to comply could affect approval of your license.
Exit interview held and report issued.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020
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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