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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610104
Report Date: 03/23/2023
Date Signed: 03/23/2023 11:07:13 AM

Document Has Been Signed on 03/23/2023 11:07 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:WOODLEY PALMS SENIOR LIVINGFACILITY NUMBER:
197610104
ADMINISTRATOR:GONZAGA, FRANCISFACILITY TYPE:
740
ADDRESS:9130 WOODLEY AVETELEPHONE:
(818) 648-3080
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 0DATE:
03/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elivra DavidTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced Annual/Case management visit to this facility. LPA Smith was greeted by Elvira David. The administrator was contacted yet staff not able to reach. LPA contacted administrator Frances Gonzaga at 9:51 am. Administrator revealed that he is currently ill and has sent documents to Community Care Regional Center in February 2023 to close the facility due to unable to maintain. Administrator also revealed no residents are residing in the home. The only occupants in the home is his mother and a friend.

LPA conducted a tour at 10:00 am of the physical plant to ensure there are no health and safety hazards and no residents are currently residing in the home.

The kitchen, living and dining room combination area observed to have adequate furnishings, sufficient lighting and observed to be clean with adequate seating.



There are four (4) bedrooms and two (2) bathrooms in the home. Each room was properly furnished with two (2) of the four (4) bedrooms empty with closets filled with family items and/or personal items/supplies. The other two (2) bedrooms occupied by the administrators mother and a friend. The two baths observed to be clean with grab bars, mats, and wash hands signs posted. The hot water for the bathrooms measured 108.9 and 115.6.

LPA did not observe any residents residing in the home or note any concerns at time of visit.

Exit interview conducted/Copy of report emailed.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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