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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610503
Report Date:
07/19/2024
Date Signed:
07/19/2024 12:46:36 PM
Document Has Been Signed on
07/19/2024 12:46 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:
FAIRHAVEN HOME 2
FACILITY NUMBER:
197610503
ADMINISTRATOR/
DIRECTOR:
MORTEL, GRACELA
FACILITY TYPE:
735
ADDRESS:
21036 CHASE STREET
TELEPHONE:
(818) 274-1809
CITY:
CANOGA PARK
STATE:
CA
ZIP CODE:
91304
CAPACITY:
6
CENSUS:
6
DATE:
07/19/2024
TYPE OF VISIT:
Prelicensing
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:
Helen Dolorfino - Caregiver
TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Perchui Milena Khurshudyan attempted to conducted a Pre-Licensing Inspection and met with the Staff/Caregiver Helen Dolorfino. Upon arrival LPA informed by S1 that the facility currently does not have an assigned Administrator. LPA explained the reason for the visit.
This is a Change of Ownership Application from facility
#197605213
to #
197610503
to operate an Adult Residential Facility Level 2. A fire clearance was approved on 02/09/2024 for a maximum capacity of six (6) ambulatory adults.
LPA was unable to complete the Pre-Licensing Inspection at this time there was no Administrator assigned.
Exit interview conducted and a copy of this report was provided to the staff/caregiver.
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Perchui Khurshudyan
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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