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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801076
Report Date: 01/21/2022
Date Signed: 01/21/2022 05:46:57 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:GOLDEN ACRES RCFEFACILITY NUMBER:
565801076
ADMINISTRATOR:BABY JANE ANGELESFACILITY TYPE:
740
ADDRESS:6437 KEYSTONE STREETTELEPHONE:
(805) 577-6936
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:4CENSUS: 0DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Baby Jane AngelesTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Required 1-year visit on 01/21/2022 at 2:30pm. Licensee/Administrator Baby Jane Angeles reported to LPA Chochian that she does not have any residents and will be closing facility. The last annual completed 01/16/2020.

Ms. Angeles communicated that this facility did not have any residents. The LPA and Ms. Angeles discussed the history of the home, and since the facility has no residents Licensee is surrendering her license and closing this facility.


The LPA conducted a physical plant tour. This facility has six rooms and two bathrooms. The LPA observed no residents. The Licensee is currently residing at the facility with her mother and aunt (mother's sister).

Closure of this facility has been confirmed during todays visit. The LPA explained the closure process to the Licensee. The LPA obtained the license during the visit. Licensee stated she has already mailed a letter of closure to the Department.

Exit interview conducted and a copy of the report was emailed to Licensee.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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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