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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610173
Report Date: 07/02/2021
Date Signed: 07/02/2021 09:53:26 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:A MAHALO CARE VILLAFACILITY NUMBER:
197610173
ADMINISTRATOR:BLANCHARD, MARKFACILITY TYPE:
740
ADDRESS:38433 ANSET DRIVETELEPHONE:
(818) 983-9720
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 0DATE:
07/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mark Blanchard/ AdministratorTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Patrick Shanahan conducted a case management visit at 9:45 AM to initiate facility closure as requested by the licensee.The LPA met with facility administrator Mark Blanchard. Entrance interview conducted.

During this visit, the LPA conducted a physical plant tour. The LPA verified through observation that no persons needing care and supervision resided in the facility. The LPA provided a closure survey to the administrator via email. The administrator will complete the closure survey and has surrendered the facility license to the LPA on this visit. An exit interview was conducted with administrator.

Exit Interview Conducted and Report Issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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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