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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610166
Report Date: 06/09/2021
Date Signed: 06/09/2021 02:39:05 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:QUARTZ HAVENFACILITY NUMBER:
197610166
ADMINISTRATOR:AYLLON, MADELEINEFACILITY TYPE:
740
ADDRESS:7250 QUARTZ AVE.TELEPHONE:
(626) 373-4386
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 5DATE:
06/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Madeleine AyllonTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted an announced Prelicensing visit. LPA met with applicant Jeffrey Alvarez and administrator Madeleine Ayllon. This application is a change of ownership from facility Quartz Garden.
LPA conducted a physical plant tour of the facility. Facility currently has five residents. All bedrooms are cleared for bedridden residents. Facility has four bedrooms of which three are shared rooms for residents. One bedroom is for staff. There are two bathrooms which were observed to have grab bars and non skid material. LPA observed all bedrooms to be properly furnished and in good order. LPA observed all common areas to be appropriately furnished. Facility has a hard wired sprinkler system. LPA observed carbon monoxide detector to be working properly. LPA toured the kitchen area for the ability to prepare and store food. LPA observed there to be a sufficient amount of perishable and non perishable food. LPA observed knives and sharp objects to be locked away and inaccessible. Medication was observed to be locked away and inaccessible. LPA observed three fire extinguishers to be charged and in good condition. There was one in the kitchen, the hallway, and the common area towards the backyard. Component III was conducted with the administrator during this visit. LPA will inform Cental Application Unit that the visit was conducted and they will notify the applicant when they are licensed. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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