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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850198
Report Date: 08/22/2022
Date Signed: 08/22/2022 11:31:56 AM


Document Has Been Signed on 08/22/2022 11:31 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:254 EAST SIDLEE LLCFACILITY NUMBER:
565850198
ADMINISTRATOR:SARREAL, JOVYFACILITY TYPE:
740
ADDRESS:254 EAST SIDLEE STREETTELEPHONE:
(905) 807-0663
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 5DATE:
08/22/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jovy SarrealTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Collateral Inspection at the facility today. The Collateral Inspection is in reference to complaint investigation, complaint control # 29-AS-20220819130001, which does not pertain to this facility.

During today's inspection the LPA interviewed Resident #1 (R1). The visit was then concluded.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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