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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850189
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:01:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/21/2022 12:01 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:143 WEST SIDLEE LLCFACILITY NUMBER:
565850189
ADMINISTRATOR:SARREAL, JOVYFACILITY TYPE:
740
ADDRESS:143 WEST SIDLEE STREETTELEPHONE:
(805) 807-0663
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 0DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Gilliana ShermanTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to 143 West Sidlee LLC to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 11:35 a.m. This will be the first Annual from their Pre-Licensing visit on 9/24/2021. Upon arrival, the LPA observed the facility to be vacant. The LPA called and met with Licensee, Gilliana Sherman shortly after and the reason for the visit was explained. Entrance interview.

The LPA and Licensee toured the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is currently empty as there are no residents or staff at the time of visit. The Licensee stated there are three (3) staff currently training and will start in a couple weeks. Residents are lined up and ready for move-in as well. Licensee will notify LPA once residents and staff move into the facility completely.

Exit interview conducted. No citations issued. Report was reviewed with Licensee and a copy was provided via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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