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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610249
Report Date: 06/21/2022
Date Signed: 06/21/2022 10:50:51 AM


Document Has Been Signed on 06/21/2022 10:50 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:RAINBOW VILLAGE SENIOR LIVINGFACILITY NUMBER:
197610249
ADMINISTRATOR:ROCK, CAROLFACILITY TYPE:
740
ADDRESS:21746 MAYAN DRIVETELEPHONE:
(213) 712-5100
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:12CENSUS: 10DATE:
06/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Mark Nemeth/ StaffTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and was greeted by the facility operator. The LPA was able to speak with operator briefly and gathered information regarding the status of the submitted application. The operator had to leave for an appointment and a staff member was designated to sign the report.

The operator is currently working with the Department of Social Services and the city of building and planning to gain a fire clearance for the home. The operator has requested an additional 60 day extension from the Department of Social Services and showed the LPA a copy of the request sent via email. The LPA was also able to speak with the application specialist assigned to this facility and confirmed that a second request had been received. This process will require approval from the bureau chief and they expect an answer by the end of the week.

The home appeared clean and there were two well stocked refrigerators in the kitchen. The LPA observed no health and safety concerns while touring the home.

Exit interview was conducted and report issued

This visit was conducted to follow up on complaint number 31-NP-20211213122447
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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