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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610258
Report Date:
01/03/2024
Date Signed:
01/03/2024 03:02:39 PM
Document Has Been Signed on
01/03/2024 03:02 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 ELDERLY
FACILITY NUMBER:
197610258
ADMINISTRATOR:
GACAYAN, CAMERON
FACILITY TYPE:
740
ADDRESS:
19825 LEADWELL ST.
TELEPHONE:
(818) 718-2750
CITY:
CANOGA PARK
STATE:
CA
ZIP CODE:
91306
CAPACITY:
6
CENSUS:
6
DATE:
01/03/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
11:35 AM
MET WITH:
Francisco Fabregas
TIME COMPLETED:
03:00 PM
NARRATIVE
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On 01/03/2024 Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced case management visit to follow up on the loss
of
control of property. LPA conducted a physical plant tour at 11:45 AM
to ensure the health and safety of the residents are protected and the physical plant is in compliance with Title 22 Regulations.
LPA requested copies of the
sixty (60) day
eviction
notice
s
for the residents
that the Administrator agreed to issue on 12/20/23
. Administrator Francisco Fabergas stated that no written documentation was provided to the residents and residents' responsible persons. Administrator stated that he verbally notified the residents and the residents' responsible persons. LPA obtained information regarding referral services for alternative housing and care options that the administrator
advised that he
has contracted with. LPA asked about
Licensee/
Administrator Cameron Gacayan and the reason for his absence. Administrator Francisco Febergas stated Cameron Gacayan had a medical appointment and couldn't attend today's visit. LPA
directed
Administrator Francisco Fabergas
to issue a 60-day notice to each resident and their responsible person(s) and provide copies to LPA Agban by close of business on this date.
Exit interview conducted. A copy of the report signed and delivered.
SUPERVISOR'S NAME:
Eva Miller
TELEPHONE:
(818) 596-4373
LICENSING EVALUATOR NAME:
Mariana Agban
TELEPHONE:
818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
01/03/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/03/2024
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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