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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610074
Report Date: 11/19/2021
Date Signed: 11/19/2021 10:57:13 AM

Document Has Been Signed on 11/19/2021 10:57 AM - 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VINTAGE HOME INC.FACILITY NUMBER:
197610074
ADMINISTRATOR:GALIZA, FILIPINASFACILITY TYPE:
735
ADDRESS:21048 VINTAGE STTELEPHONE:
(818) 700-9353
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 4CENSUS: 4DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Filipinas Galiza/ AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home in order to conduct an Infection control annual visit. LPA was greeted by the facility administrator and had his temperature taken before being allowed entry.

A tour of the physical plant was conducted for for health and safety. The smoke alarm in the living room was tested and functioned properly. The carbon monoxide detector was also tested next to the residents rooms and it functioned properly. The fire extinguisher appeared to be in the green and in working order.

No health and safety concerns were observed during todays visit. Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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