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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610195
Report Date: 11/30/2022
Date Signed: 11/30/2022 09:48:13 AM


Document Has Been Signed on 11/30/2022 09:48 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:JRBELLA HOME FOR THE ELDERLYFACILITY NUMBER:
197610195
ADMINISTRATOR:TUMALIUAN, NESTORFACILITY TYPE:
740
ADDRESS:17100 CALAHAN STREETTELEPHONE:
(818) 524-8613
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 4DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nestor Tumaliuan/ AdministratorTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct an Infection Control Annual. The LPA had his temperature taken and was asked the COVID-19 questions before being allowed entry. The LPA was greeted by the facility administrator and explained the reason for the visit. The inspection tool was used to conduct this annual.

The home consists of 6 bedrooms 4 bathrooms. The smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguisher was observed next to the front door and was last serviced on 11/29/22. The home is currently following their infection control plan and no deficiencies were observed during todays visit.

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: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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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