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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850081
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:07:51 PM

Document Has Been Signed on 08/02/2022 04:07 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:STADIUM PLACE HOMEFACILITY NUMBER:
425850081
ADMINISTRATOR:CINDY BAKERFACILITY TYPE:
734
ADDRESS:961 STADIUM PLACETELEPHONE:
(805) 691-9036
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 5CENSUS: 5DATE:
08/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Cindy Baker, Administrator, and Donna PiepzyckiTIME COMPLETED:
04:20 PM
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On 8/2/22 at 10:18 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced visit to investigate an incident of suspected abuse which the facility self-reported. LPA met with Cindy Baker, Administrator, and Donna Pieprzycki, RN/Nurse Consultant, to inform of the reason for the visit.

LPA interviewed administrator, nurse consultant, staff, credible witness, obtained documentation, and reviewed records. Further investigation is needed. LPA will return at a later date to continue the investigation.

Exit interview conducted and a copy of the report emailed to administrator and nurse consultant.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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