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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800734
Report Date: 08/01/2023
Date Signed: 08/01/2023 04:34:18 PM

Document Has Been Signed on 08/01/2023 04:34 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:HILLCREST ROYALEFACILITY NUMBER:
565800734
ADMINISTRATOR:INGA JAKOBOVICHFACILITY TYPE:
740
ADDRESS:190 EAST HILLCREST DRIVETELEPHONE:
(805) 371-0035
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 145CENSUS: 87DATE:
08/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Inga JackobovichTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a continuation to a required annual visit at 1:45 p.m. The LPA was greeted by staff and informed them of the reason for the visit. This is an annual continuation, which began on 06/19/2023.

RECORDS: The LPA began a records review at 2:00 p.m., the LPA began the records review by reviewing staff associations and compared the Licensing Facility Personnel Report Summary dated 6/19/2023 and 8/1/2023 against the facilities most recent LIC 500 dated 3/22/2023 and Guardian. The LPA identified 7 staff who are in need of further record review.

Due to time constraints, the LPA will return at a later date to complete the inspection.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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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