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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801816
Report Date: 06/21/2021
Date Signed: 06/21/2021 01:59:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:EL POMAR MANORFACILITY NUMBER:
405801816
ADMINISTRATOR:PEGGY THOMPSONFACILITY TYPE:
740
ADDRESS:3475 EL POMAR DRIVETELEPHONE:
(805) 239-0993
CITY:TEMPLETONSTATE: CAZIP CODE:
93465
CAPACITY:6CENSUS: 0DATE:
06/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Braianne Fry/ Licensee DaughterTIME COMPLETED:
01:30 PM
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At 12:15pm on 06/21/2021, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to conduct a facility closure visit. LPA received email with copy of License and list of 4 resident relocations as a function of facility closure. LPA toured facility with Licensee's daughter Brianne Fry. All rooms in facility were in various stages of packing which was evidence of no one residing in the facility. LPA toured the entire facility and found no evidence of anyone living in the facility at this time. LPA observed the refrigerator and there were limited items of sodas and water. Mrs. Fry stated that License's family member became ill and the family wanted to focus on the care of the family member witch was the reason for the facility closure.

Exit interview, report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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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