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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610258
Report Date: 07/08/2022
Date Signed: 07/08/2022 10:48:57 AM


Document Has Been Signed on 07/08/2022 10:48 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:HOME FOR THE ELDERLYFACILITY NUMBER:
197610258
ADMINISTRATOR:GACAYAN, CAMERONFACILITY TYPE:
740
ADDRESS:19825 LEADWELL ST.TELEPHONE:
(818) 718-2750
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 3DATE:
07/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Francisco Fabrigas, Camaron GacayanTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Michael Cava conducted a Case Management visit to the facility to conduct a Component III orientation. LPA met with both administrators, Francisco Fabrigas and Camaron Gacayan, and went over the Component III power point presentation with them. At the end of the Component III, both administrators were given the opportunity for questions and answers. Both administrators carry an updated administrator certificate. The pre-licensing was conducted on 6/10/2022. Pursuant to title 22, facility is in compliance with Title 22 Regulations during that visit. In addition to the Component III, LPA conducted an inspection of the physical plant, which facility continues to remain in compliance with title 22. No deficiencies were observed during the visit.

Based on the day's inspection and completion of Component III, facility appears ready for licensure. Both administrator were advised and a copy of this report given. CAB will also be notified of the completion of the Component III and pre-licensing.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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