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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850416
Report Date: 08/16/2024
Date Signed: 08/16/2024 02:03:09 PM


Document Has Been Signed on 08/16/2024 02:03 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:MARICAR'S MANOR IIFACILITY NUMBER:
565850416
ADMINISTRATOR:MARTNEZ, TINA MARIEFACILITY TYPE:
740
ADDRESS:1168 ARCANE STREETTELEPHONE:
(805) 210-2480
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
08/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Calixto Calixtro - Caregiver TIME COMPLETED:
02:30 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
Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Incident visit at 1:00 p.m. for the purpose of investigating self-reported incident reports. Upon arrival, LPA met with staff and explained the reason for the visit. During the visit LPA called the Administrator Tina Marie Martinez over the phone who stated that caregiver Calixto Calixtro can sign in their place.

On 08/02/2024, the Department received a incident report stating on the evening of 07/31/2024 at approx 10pm, local police department arrived to the home due to Client #1 (C1) stating they were being physically abused by staff.

At approx 1pm, LPA conducted physical plant, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation. LPA has determine further investigation is needed and will return at a later date to complete the investigation if warranted.

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
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