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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610121
Report Date: 12/04/2020
Date Signed: 12/04/2020 03:18:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:WEST HILLS ASSISTED LIVINGFACILITY NUMBER:
197610121
ADMINISTRATOR:MILLAN, JONATHANFACILITY TYPE:
740
ADDRESS:7055 SHOUP AVENUETELEPHONE:
(818) 883-7201
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:90CENSUS: DATE:
12/04/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ginger Po and Jonathan MillanTIME COMPLETED:
02:30 PM
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COMP II by CAB successfully completed
Facility Type: RCFE
Application Type: CHOW
Capacity: 90
Census: 45
Method: Telephone call with CAB Analyst
COMP II Participants: Ginger Po, Applicant and Jonathan Millan, Administrator

Ginger Po and Jonathan Millan participated in COMP II via telephone call with analyst Kathleen Carroll at CAB. Identification of the Ginger Po and Jonathan Millan were verified by photo ID that was submitted with the application. During COMP II, Ginger Po and Jonathan Millan confirmed the understanding of Title 22. Component II was successfully completed. Ginger Po and Jonathan Millan have been advised to transmit signed LIC 809 to CAB.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Kathleen CarrollTELEPHONE: (916) 651-3129
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020
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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