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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421701694
Report Date: 06/11/2024
Date Signed: 06/20/2024 09:31:09 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/20/2024 09:31 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GANTOUS HOMEFACILITY NUMBER:
421701694
ADMINISTRATOR/
DIRECTOR:		GANTOUS,SHELBY&CAROLFACILITY TYPE:
735
ADDRESS:1514 NORTH MILLER STTELEPHONE:
(805) 925-6734
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 1CENSUS: 1DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Carol Gantous, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Erika Miller arrived unannounced to conduct a one year required annual visit. LPA rang the doorbell, called licensee and left a voicemail, and left a business card at the door. LPA received a voicemail from licensee the next day, indicating they had a family emergency and would be unavailable at this time. LPA contacted Tri-Counties Regional Center, who had received the same information.

LPA observed the exterior of the facility and did not note any hazards. LPA will return at a later date to continue the annual visit.

Exit interview, report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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