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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610080
Report Date: 10/08/2021
Date Signed: 10/08/2021 06:24:14 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:PROSPERITY ARTS & CRAFT INCFACILITY NUMBER:
197610080
ADMINISTRATOR:SMITH, WANDAFACILITY TYPE:
740
ADDRESS:8538 WILBUR AVENUETELEPHONE:
(818) 945-6005
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 1DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Crystal Rebollar, Lefaye JeffersonTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required Annual visit to the facility. LPA met with staff Crystal Rebollar and Lefay Jefferson. Covid screening done at entry but no questionaire was completed. Only temperature check and log in.

A copy of the mitigation plan was requested. The one on file was not the approved copy. A tour of the facility was conducted. There were no hand washing signs in the restrooms. The facility has live in staff and need to do a LIC500 and LIC610E need to be updated.

There are no health and safety hazards observed during this visit. LPA did check on resident who was in her LPA room watching TV. The resident has already received her vaccination.

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

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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