<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801904
Report Date: 04/03/2024
Date Signed: 04/04/2024 09:47:47 AM


Document Has Been Signed on 04/04/2024 09:47 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:BREEN RESIDENTIAL CAREFACILITY NUMBER:
565801904
ADMINISTRATOR:EDWARD M. BREENFACILITY TYPE:
740
ADDRESS:1168 ARCANE STREETTELEPHONE:
(805) 579-7933
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 3DATE:
04/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Calixtro Alex Calixtro, Tina Marie and Maricar LeeTIME COMPLETED:
03:53 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A case management visit conducted by Licensing Program Analyst (LPA) Zabel Chochian in conjunction with the Pre licensing visit for change of ownership from BR Care, INC to Maricar's Manor, INC. LPA met with designated staff Tina Marie Martnez staff Calixtro Alex Calixtro and new applicant Maricar Lee.

LPA inspected facility inside and out for Fire Safety, Personal Accommodations and Services, Food Service, and Medication Procedures. LPA measured hot water at 107 degrees Fahrenheit in resident restroom which is above 105-120 degrees Fahrenheit required in regulation. Rooms were inspected. The physical plant was toured inside and out.

No health and safety hazards were noted during inspection at this time.

Exit held and report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1