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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850141
Report Date: 07/25/2024
Date Signed: 07/25/2024 12:16:38 PM


Document Has Been Signed on 07/25/2024 12:16 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:AEGIS LIVING VENTURAFACILITY NUMBER:
565850141
ADMINISTRATOR:LANCE SHENKFACILITY TYPE:
740
ADDRESS:4964 TELEGRAPH ROADTELEPHONE:
(805) 650-1114
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:100CENSUS: 83DATE:
07/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jeanphilippe Rollet, Administrator TIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection at the facility today. At 10:46 a.m., the LPA met with Administrator Jeanphilippe Rollet and explained the reason for today's inspection.

The reason for today's inspection is to follow up on a self-reported incident received on 07/10/2024. The report pertains to Resident #1 (R1) reporting a stolen vehicle that was taken by Staff #1 (S1). At 10:55 a.m., the LPA conducted an interview with the Administrator. At 11:02 a.m., the LPA received copies of pertinent document. At 11:20 a.m., the LPA along with the Administrator conducted a physical plant tour. At 11:37 a.m., the LPA conducted an interview with R1.

No immediate health and safety concerns were observed during today's inspection.

Additional report may follow if warranted.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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