191221159-1-4-2024-31-AS-HRAI-CZ6UVF-20240104145505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191221159
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:56:01 PM

Document Has Been Signed on 01/04/2024 02:56 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:	MAHARLIKA HOMES		FACILITY NUMBER:	191221159
ADMINISTRATOR:	GARDOSE, NOELLIE L.		FACILITY TYPE:	740
ADDRESS:	17843 CANTARA STREET		TELEPHONE:	(818) 343-3936
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	4	CENSUS: 4	DATE:	01/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Monique Gardose, Administrator Designee		TIME COMPLETED:	03:20 PM

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At 12:00 PM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met the staff Julieta Ranches who granted access to the facility. LPA explained the reason for the visit. Administrator Designee Monique Gardose arrived at 12:18 PM and LPA explained the reason for the visit. Physical tour was conducted with the Administrator Designee and LPA observed the following:

It is a single story building with 5 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 4 nonambulatory residents. Approved hospice waivers for 2. LPA observed signs posted at the front for the facility’s visitation and masking policies. Additional postings inside included confidential complaint contacts, ombudsman contacts, emergency disaster plan, facility sketch, license, house rules, personal rights. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair.

Kitchen: At 12:20 PM, LPA observed an adequate supply of perishable and non-perishable food. The stove hood was clean and surfaces were sanitary. Sharps and cleaning solutions were locked below the sink.

Medication: Medications: At approximately, 12:25 PM, LPA observed medications are centrally stored and locked in a locked cabinet in the living room.

Bedrooms: The facility had 5 private bedrooms. One bedroom served as the staff room. The staff room was clean and free of hazards. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition.

Bathrooms: The facility had 2 bathrooms. All bathrooms contained liquid soap, paper towels, bidets, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 12:35 PM, LPA measured the water temperature in the resident bathroom to be 111.4 degrees Fahrenheit.

Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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: MAHARLIKA HOMES	FACILITY NUMBER: 191221159
	VISIT DATE: 01/04/2024

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Common Areas: At 12:43 PM, LPA measured the room temperature to be 69 degrees Fahrenheit. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.

Laundry/ Garage: The laundry room and garage was adjacent to the staff room. Detergents were locked above the appliances.

A fire extinguisher hung near the appliances. It was fully-charged and last serviced on 05/02/2023. All emergency exit paths were free from obstructions. Exit gates were unlocked.

Smoke detectors/carbon monoxide: At 12:42 PM, Administrator tested the living room smoke detector to be operational. At 12:42 PM LPA also tested the carbon monoxide detector to be operational.

Outside areas: The outside area contained gardened spaces. The front yard contained a covered patio area with furniture in good condition.

Between 1:20 PM to 02:30 PM, LPA reviewed records of four (4) clients and two (2) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, Administrator certificate, and LIC500.

During today's inspection, the facility is in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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