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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609996
Report Date: 08/18/2021
Date Signed: 08/18/2021 11:18:18 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: 6DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lily CabanbanTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required annual visit. LPA was greeted by Lilia Cabanban the Licensee/Administrator. There were 6 residents currently in the home. The purpose of the visit was given and LPA was screened at the front door.

LPA observation at entry was the front table had screening supplies, mask, gloves, hand sanitizer, thermometer, and note book to log each person that had visited. The Covid 19 protocol signage was posted throughout the facility. The mitigation plan was on file and was approved on 7-29-2021.

The mitigation was complete and approved. All staff were wearing face mask and residents were practicing social distancing in the common area. A brief tour of the faciity was completed and hand washing signs were observed in each resroom. Each resident room was clean and had hand santizer, wipes or tissue next to their bed.
During the visit one of the resident had a visitor, and doctors visit. Administrator was informed about the informational meeting today at 1pm.

No citations issued, exit interview conducted.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Angelica ArambuloTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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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