191220673-7-23-2024-31-AS-AAEA-D7FSNK-20240723140139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191220673
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:01:52 PM

Document Has Been Signed on 07/23/2024 02:01 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROBINSON MANOR II		FACILITY NUMBER:	191220673
ADMINISTRATOR/ DIRECTOR:	RETHA DE JOHNETTE		FACILITY TYPE:	735
ADDRESS:	628 ROYCE STREET		TELEPHONE:	(626) 791-2486
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY: 6		CENSUS: 5	DATE:	07/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Administrator, Retha De Johnetta		TIME VISIT/ INSPECTION COMPLETED:	02:15 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) Antonia Alvizar-Ettima conducted an unannounced Required 1-Year visit to this facility. LPA knocked on the front door no answer. LPA then contacted Administrator, Retha De Johnette via-phone and gained enterie and discussed the purpose of this visit. This facility retains six (06) clients with Level 3 Intellectual Disabilities, placed by the San Gabriel/Pomona Regional Center. At 10:35am, LPA Antonia Alvizar-Ettima conducted a tour of physical plant inside and out. The facility consists of a living and dining room, kitchen and five bedrooms and three bathrooms. One (1) bedroom is used as an office, another bedroom is a staff room and remaining three double occupancy bedrooms are used for clients. The office room has its own bathroom. 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. An adequate supply of perishable and non-perishable foods was observed to be properly stored on site. The Laundry room was located to the left from the kitchen. LPA observed washer and dryer, and both were functional. All client bedrooms were sufficiently furnished for double occupancy, fixtures worked and no hazards were observed. Bathrooms were sanitary, the hot water was tested between 110.3 -114.1*F. The facility also contains an outdoor area, consisting of a patio, garden, garage and small cottage building. No hazardous items were observed in the yard, garage, or other building. Both the garage and the spare building are used as storage. LPA Antonia Alvizar-Ettima observed build in ramps in front of building and in the backyard which was built for the emergency exit to the passage way, that leads to the front of the facility.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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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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 MANOR II	FACILITY NUMBER: 191220673
	VISIT DATE: 07/23/2024

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At 11:30am LPA Antonia Alvizar-Ettima reviewed clients medication supply and medication administration records. 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 07/11/2024.

At 12:30pm LPA Alvizar- Ettima reviewed all client files. The files observed to contain signed admission agreements, Identifying information, Medical assessment, personal rights, need and services appraisals, psychiatric evaluation report, consent forms, personal and incidental fund logs, inventory sheet for personal items and valuables, and other documents as required by the Licensing Office and Regional Center. LPA Alvizar-Ettima reviewed and discussed clients P&I records. The Administrator explained how she is safeguarding clients finances and as per explanation the Licensee is following the Title 22 Regulations.

At 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: 07/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC809 (FAS) - (06/04)

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