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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220547
Report Date: 12/27/2024
Date Signed: 12/27/2024 03:37:47 PM

Document Has Been Signed on 12/27/2024 03:37 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROBINSON'S MANORFACILITY NUMBER:
191220547
ADMINISTRATOR/
DIRECTOR:		ROBINSON, REGINALDFACILITY TYPE:
735
ADDRESS:51 WEST ALTADENA DRIVETELEPHONE:
(626) 798-1666
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 4DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Retha De Johnette & Direct Support Professional (DSP), Claudia Cruz-Mendez TIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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At 9:45am, Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required 1-Year visit to this facility. LPA met with Administrator and Direct Support Professional (DSP) and gained entry and discussed the purpose of this visit.

The facility capacity is six (06) clients current census four (04) with Level 2 Intellectual Disabilities, placed by the San Gabriel/Pomona Regional Center.

At 10:30am, LPA and Staff conducted a tour of physical plant inside and out. The facility consists of a living and dining room, kitchen, two (02) bathrooms. A total of four (04) bedrooms of which two (02) are single occupancy client bedrooms, one (01) double occupancy client bedroom and one (01) staff bedroom. Common areas were clean and appropriately furnished.

Kitchen area was clean and hazardous items (knifes, other sharp items, toxins and other chemicals) were properly secured. LPA observed kitchen cabinets, stocked with canned goods. Snacks included chips, and fresh fruit are available. The food service area had Licensing requirement of (7) day nonperishable, and (2) day perishable. Facility has extra freezer located in the garage, with frozen meat and vegetables. The Laundry room was located in the attached garage. LPA observed washer and dryer, and both were functional. The surrounding grounds exit gate was open and easily accessible. Outside area had clear passageways, with no visible hazards. Furniture available outside for client's comfort and use.

All client bedrooms were sufficiently furnished for double occupancy, fixtures worked and no hazards were observed. Bathrooms were sanitary with functional fixtures and There are grab bars and non-skid mats. The hot water was tested between 112.5 -116.7*F.

Cont. LIC 9099-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROBINSON'S MANOR
FACILITY NUMBER: 191220547
VISIT DATE: 12/27/2024
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At approximately 11:00am LPA reviewed clients medication supply and medication administration records. Medication storage locked and secured. No discrepancies were noted. All smoke detectors were functional. Fire extinguishers were fully charged, and the facility's last fire and earth-quick drill was conducted on 10/23/2024.

At approximately 11:20am LPA reviewed all client files. The files observed to contain documents as required by the Licensing Office and Regional Center. LPA reviewed and discussed clients P&I records. The Administrator explained how she is safeguarding client’s finances and as per explanation the Licensee is following the Title 22 Regulations.

At about 1:30am LPA Alvizar-Ettima reviewed the Staff files. The records contained, Personal requirements/job applications; health screenings and criminal record clearances, First Aid/CPR Certificates were current, and all training records were present.

No immediate health and safety hazard is noted during this visit.

Exit interview was conducted, a copy of report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
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