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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610076
Report Date:
10/12/2021
Date Signed:
02/13/2023 11:53:44 AM
Document Has Been Signed on
02/13/2023 11:53 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:
ELEVATED HOME HEALTH
FACILITY NUMBER:
197610076
ADMINISTRATOR:
GOODWIN, BYRANISHA
FACILITY TYPE:
740
ADDRESS:
44663 2ND STREET EAST
TELEPHONE:
(702) 823-8166
CITY:
LANCASTER
STATE:
CA
ZIP CODE:
93535
CAPACITY:
2
CENSUS:
DATE:
10/12/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
03:00 PM
MET WITH:
Byranisha Goodwin
TIME COMPLETED:
03:30 PM
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SUPERVISOR'S NAME:
Nichelle Gillyard
TELEPHONE:
(818) 596-4341
LICENSING EVALUATOR NAME:
Shira Stamps
TELEPHONE:
(818) 669-6375
LICENSING EVALUATOR SIGNATURE:
DATE:
10/12/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/12/2021
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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