191222021-5-1-2024-31-AS-GSAO-D4UR6T-20240501124515

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222021
Report Date: 05/01/2024
Date Signed: 05/01/2024 12:45:35 PM

Document Has Been Signed on 05/01/2024 12:45 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 HOME II		FACILITY NUMBER:	191222021
ADMINISTRATOR/ DIRECTOR:	LEDESMA, NOELLIE		FACILITY TYPE:	735
ADDRESS:	17345 BURTON STREET		TELEPHONE:	(818) 708-0627
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY: 4		CENSUS: 4	DATE:	05/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:58 AM
MET WITH:	Noellie Ledesma		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

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On 05/01/24, at 8:58 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA was met by Noellie Ledesma, the licensee.

LPA asked for the census, client, and staff files. The physical tour started at 9:45am and LPA observed the following:

Temperature of facility wall thermostat is observed and set to 77 degrees Fahrenheit.

There is no garage only carport next to the house. Backyard: There is a table set and chairs for clients use. There is enough seating for four (4) clients. There is no pool or any bodies of water. There is one (1) shed in the backyard.

There is a staff office that has access to the laundry room which has a washer and dryer. There are chemicals that are locked and inaccessible to the clients. The staff office has additional signs like the disaster plan, YES sign and Ombudsman. The staff office has an extra refrigerator and a freezer with extra food. There is one is,(one) staff bedroom located inside the staff/office room.

Medications are in a cabinet locked and secured in the staff office on your left-hand side. The first aid kit and manual are also kept in a cabinet in the staff room. It is inaccessible to clients.

LIC 809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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 HOME II	FACILITY NUMBER: 191222021
	VISIT DATE: 05/01/2024

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Kitchen area was observed to be clean. The refrigerator is fully stacked and has the food menu. The food service area, food storage and supply perishable and seven (7) day supply of nonperishable foods were observed. The kitchen food supply was observed and sufficient for the four (4) clients currently residing there. There is an excess of perishables in several of the cabinets. The sharps and toxins are kept under the sink locked and inaccessible to the clients. There are three (3) fire extinguishers throughout the house and smoke detectors. The fire extinguisher has a date of 04/2024 and fully charged. The smoke detectors were functioning properly along with the carbon monoxide.

Living and dining room furniture is accessible for four (4) clients. There is a television and enough seating for four (4) clients. There is internet accessibility a phone line available for client use. Furniture was observed to be in good condition and the fireplace has a covering around it. There is a carbon monoxide against the wall. There is a large fish tank located in the living/dining room area.

There is another carbon monoxide detector in between two (2) client rooms against the wall.

Bedrooms: There are three (3) client bedrooms. One (1) client bedroom is shared with a private bathroom. The other two (2) bedrooms are single, occupied. There is another bathroom located by the entrance of the house. The bathrooms read a temperature between 106.5 and 107.8 Fahrenheit. All bedrooms are properly furnished. The bathrooms have proper toiletry and grab bars. There is an extra closet in the hallway with extra linen.

Administrative: There is no annual fee due. The surety bond/Insurance plan are updated and expire April 2025 and October 2024.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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