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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610523
Report Date: 12/05/2023
Date Signed: 02/20/2024 12:33:33 PM

Document Has Been Signed on 02/20/2024 12:33 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:CRT PROGRAMS-SYLMARFACILITY NUMBER:
197610523
ADMINISTRATOR:STORY, LAWRENCEFACILITY TYPE:
772
ADDRESS:14124 BUCHER AVENUE, RTP-ETELEPHONE:
(310) 709-7355
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 16CENSUS: 0DATE:
12/05/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee Shahrouz Ghodsian and Administrator Lawrence StoryTIME COMPLETED:
12:00 PM
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Facility Type: SRF
Application Type: Initial
Capacity: 16
Census (if any clients in care): 0
COMP II Participants: Licensee Shahrouz Ghodsian and Administrator Lawrence Story
Interview Method: MS TEAMS Meeting

On 12/5/2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Biridiana Cisneros
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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