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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610258
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:58:48 PM


Document Has Been Signed on 04/10/2024 01:58 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:HOME FOR THE ELDERLYFACILITY NUMBER:
197610258
ADMINISTRATOR:FRANCISCO FABREGASFACILITY TYPE:
740
ADDRESS:19825 LEADWELL ST.TELEPHONE:
(818) 718-2750
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 2DATE:
04/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Francisco Fabergas- AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted a case management visit to follow up on the facility closure. At 1:55 PM LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. LPA met with Administrator Francisco Fabergas and explained the reason for the visit. Facility's current census is 2. Administrator continues to work with placement agencies and families of the residents for their relocation. LPA reminded Administrator that the 60-day notice was due on 03/15/24. Administrator stated that the relocation of R1 will be on April 11th 2024 and for R2 will be on April 14, 2024. LPA reminded Administrator to email any follow up updates to LPA Agban and LPM Miller.

Exit Interview conducted a copy of this report delivered

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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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