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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222021
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:32:51 PM

Document Has Been Signed on 03/29/2022 12:32 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:MAHARLIKA HOME IIFACILITY NUMBER:
191222021
ADMINISTRATOR:LEDESMA, NOELLIEFACILITY TYPE:
735
ADDRESS:17345 BURTON STREETTELEPHONE:
(818) 708-0627
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 5DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Noellie Ledesma TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA was greeted by staff and LPA’s temperature was taken. LPA Martinez later met with Administrator Noellie Ledesma This is a level four (3) care facility. At 11:20 a.m. a physical tour the of the facility was conducted and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Facility has sufficient PPE supplies for more than 30 days. High traffic areas are cleaned and sanitized frequently. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps, cleaning supplies and medications are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 11:49 a.m. and appear to be functional. Fire extinguisher has a service date of 04/30/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 68.0 F. There is a staff office which leads into the laundry area and the staff bedroom. Laundry supplies are locked and inaccessible to clients. Clients Rooms: Facility has four (4) bedrooms of which one (1) is designated for a live-in staff. Two (2) of the bedrooms are shared. All four (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the clients. Towels are not shared. All rooms have adequate lighting. Bathrooms: There are two (2) bathrooms in the facility. The hot water was tested and measured 112.3 F. All trash cans located in the bathrooms had tight fitting lids. Outside Area: LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. There is a shed that is used for additional storage is maintained locked.

No deficiencies cited at this time. Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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