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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610397
Report Date: 07/19/2024
Date Signed: 07/19/2024 04:04:58 PM

Document Has Been Signed on 07/19/2024 04:04 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ICON-ADPFACILITY NUMBER:
197610397
ADMINISTRATOR/
DIRECTOR:		BROWN, DEWALTFACILITY TYPE:
775
ADDRESS:2369 LINCOLN AVETELEPHONE:
(626) 926-3519
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 120CENSUS: 63DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Assistant Administrator (AA), Steven James and Administrator, DeWalt Brown TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA), Antonia Alvizar - Ettima conducted an unannounced Required 1-year inspection at this facility at approximately 10:15 a.m. Upon arriving, LPA met with AA and later Brown joined and the reason for the visit was explain.

AA and LPA conducted a tour of the physical plant at approximately 11:00a.m. to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The common areas were observed for the ability to safely serve the needs of clients. Reception/Activity area, kitchen, five (5) activity rooms, three (3) bathrooms, detached garage and outdoor areas. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be sanitary and furnished appropriately. Clients where observed to be watching a movie.


Due to time constraints LPA was unable to issue citation for the defectives observed at the time of this visit. LPA will return at a later time to complete this required 1- Year visit and issue citations.

Exit interview conducted/Copy of report given
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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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