<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610249
Report Date: 03/17/2023
Date Signed: 03/17/2023 02:38:41 PM


Document Has Been Signed on 03/17/2023 02:38 PM - 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:
03/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Mark Nemeth/ Staff
TIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs), Angela Panushkina and Mariana Agban, arrived at the home and were greeted by the staff, Mark Nemeth. Applicant arrived shortly after and LPAs explained the reason for the visit.

At 1:00pm, LPAs toured the entire home and it appeared to be clean and sanitary and no immediate health and safety issues were observed.

The Applicant has removed all medications from his possession and all residents have their medications in their own rooms. The Applicant informed the LPAs that he is still working with the Department of Social Services and the City of Building and Planing to gain a fire clearance for the home. During todays visit LPAs observed ten (10) residents. LPAs discussed relocation to bring down the capacity to 6. Application status is pending.

Exit interview was conducted.

Copy of this report signed and issued to the Applicant.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1