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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850244
Report Date: 03/04/2024
Date Signed: 03/04/2024 11:21:33 AM

Document Has Been Signed on 03/04/2024 11:21 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:PALS SKILLS CENTERFACILITY NUMBER:
565850244
ADMINISTRATOR:POURAN MOUSAZADEHFACILITY TYPE:
775
ADDRESS:1310 E MAIN STREETTELEPHONE:
(562) 489-3859
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 30CENSUS: 5DATE:
03/04/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Pouran MousazadehTIME COMPLETED:
11:30 AM
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
Licensing Program Analysts (LPAs) Martha Arroyo and Teresa Camara conducted a collateral visit at the facility above. Upon arrival, LPAs met with Administrator Pouran Mousazadeh and explained the reason for the visit. Entrance interview conducted.

During today’s visit, LPAs conducted interviews with the Administrator at 11:06 a.m. and one resident at 10:52 a.m.

Exit interview conducted. The report was reviewed with the Administrator and a copy was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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