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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610165
Report Date: 04/08/2021
Date Signed: 04/08/2021 11:06:58 AM

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:MCNULTY VILLAFACILITY NUMBER:
197610165
ADMINISTRATOR:WOOD, CHERIEFACILITY TYPE:
740
ADDRESS:20724 MCNULTY PL.TELEPHONE:
(818) 395-6037
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 5DATE:
04/08/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cherie WoodTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Wendell Smith conducted a pre-licensing visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the visit was conducted virtually through face-time with Cherie Wood. Application is a change of ownership application..
LPA was given a physical plant tour of the facility. Facility is fire cleared for two ambulatory, three non ambulatory, and one bedridden resident. Bedroom #1 and 2 are cleared for ambulatory only. Bedroom #3 and #4 are cleared for non ambulatory and one bedridden may be in either room #3 or #4.
Facility has one bathroom designated for residents and one bathroom was designated for staff. LPA checked the kitchen area of the facility for the ability to prepare and store food. Next to the kitchen was a laundry room that is inaccessible from residents. LPA observed the backyard of the facility to be free of clutter and debris. All exit doors were appropriately alarmed. LPA observed the required postings upon entrance to the facility.
Exit Interview conducted. Copy of report emailed for signature.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021
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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