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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221317
Report Date: 11/04/2023
Date Signed: 11/04/2023 04:43:08 PM

Document Has Been Signed on 11/04/2023 04:43 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.ASC, 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: 6DATE:
11/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Abbygail Chambless - StaffTIME COMPLETED:
04:42 PM
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A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Abbygail Chambless who called Administrator Joy Magdangal-Bonnet and designated her to sign the report. Purpose of visit was stated. This is a North Los Angeles Regional Center (NLARC) vendored facility level III.

A tour of the physical plant was conducted at 1:45 PM and the following were noted:

The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear mask and must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has three (3) shared client bedrooms and two (2) bathrooms. There is an additional room designated for staff use and there is an additional dwelling unit for the staff attached to the house but has separate ingress and egress and no access from inside the house. There is also a shed at the backyard being used as a storage for supplies and old equipment.

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2023
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TOMANENG GUEST HOME I
FACILITY NUMBER: 191221317
VISIT DATE: 11/04/2023
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(continued from LIC 809)

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet in the kitchen. Food: The facility is observed to have sufficient food supply for the clients both perishable and non-perishable. Temperature of facility wall thermostat is set at 72.0°F and observed to be within the required range. Fire extinguisher: There are two (2) fire extinguishers in the facility, one (1) in the kitchen and another one (1) in the hallway in between bedrooms. Extinguishers were observed to be operable and last bought on 08/26/23. Smoke and carbon monoxide alarms are tested and observed to be operable.
Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 113.9°F and within the required range.
Laundry area is located in the kitchen. Cleaning solutions and laundry detergents are observed kept in the locked cabinet in the kitchen.
Client records were reviewed for current IPP and/or Needs and Service plans. physician report, admission agreements and P & I funds. Client records appeared to be complete and current.
Medication was observed to be inaccessible and stored in a secured cabinet. There are two (2) complete First Aid kits in the medication cabinet.
Staff records were checked. Staff present has criminal record clearances and associated to this facility.
Staff records appear to be complete and current.

Disaster drill was last conducted on 10/23/23. Required posting are observed to be complete and current and displayed properly at the facility.

There was no immediate health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2023
LIC809 (FAS) - (06/04)
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