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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610258
Report Date: 02/01/2024
Date Signed: 02/01/2024 09:47:12 AM


Document Has Been Signed on 02/01/2024 09:47 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
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: 6DATE:
02/01/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH: Francisco FabergasTIME COMPLETED:
09:45 AM
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LPM Eva Miller and LPAs Mariana Agban, Michael Cava, Raymond Comer and Milena Khurshudyan conducted informal closure meeting. Licensing Team met with Administrator Francisco Fabergas and discussed the next steps for the forfeit of the license and closure the facility. Administrator stated the facility has a census of 6 residents. Administrator confirmed that 60- days eviction notices have been mailed to the responsible parsons of the residents as of Jan 15, 2024. Administrator was advised to sent weekly Resident Roster for the closure. In addition, Administrator was advised to notify LPA Agban of the new location of each resident. Exit interview conducted and a copy of LIC 809 provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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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