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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221317
Report Date: 09/28/2022
Date Signed: 09/28/2022 01:22:43 PM

Document Has Been Signed on 09/28/2022 01:22 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TOMANENG GUEST HOME IFACILITY NUMBER:
191221317
ADMINISTRATOR:ESTELA TOMANENGFACILITY TYPE:
735
ADDRESS:11204 GAVIOTA ST.TELEPHONE:
(818) 831-5767
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 3DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Joy Magdangal-BonnetTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and was greeted by the facility administrator,. LPA informed the administrator the visit was an infection control annual. All COVID-19 protocols were covered before allowing the LPA enter the home.

The annual care tool was used to complete the inspection. The home has three bedrooms for residents use and one room for staff. There are also 2 bathrooms at the home. The smoke alarms and carbon monoxide detectors were tested and all functioned properly. The fire extinguisher was last purchased on 10/5/21 and appeared functional.

The facility is currently following their infection control plan and no deficiencies were observed during the visit.
Exit interview conducted and report issued,.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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