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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610195
Report Date: 02/10/2025
Date Signed: 02/10/2025 10:25:18 AM

Document Has Been Signed on 02/10/2025 10:25 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JRBELLA HOME FOR THE ELDERLYFACILITY NUMBER:
197610195
ADMINISTRATOR/
DIRECTOR:		TUMALIUAN, NESTORFACILITY TYPE:
740
ADDRESS:17100 CALAHAN STREETTELEPHONE:
(818) 524-8613
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/10/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Nestor TumaliuanTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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On 02/10/25, at 9:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, case management due to changes to facility sketch. The final approval was conducted by the Department of Building and Safety on 06/03/24. The facility now has seven (7) rooms instead of the original sketch of six (6) rooms. Six (6) bedrooms are for residents and one (1) bedroom is for staff. The Fire Inspection’s final approval was conducted on 01/15/25 with an updated LIC 850. A new LIC 200 was sent to the Community Care Licensing Department on 01/13/25 and the Pre-Inspection/Consultation Request of 1083.00 was paid on 10/18/24. All the documents have been paid and updated for the above facility.

A copy of all the documents have been provided to the Licensee/Administrator, an exit interview was conducted, no citation(s) were issued and a copy of this report was given to the licensee/Administrator.
Troy AgardTELEPHONE: (818) 596-4334
Gina SaucedoTELEPHONE: (818) 304-3057
DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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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