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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222099
Report Date: 03/27/2024
Date Signed: 03/27/2024 02:32:04 PM

Document Has Been Signed on 03/27/2024 02:32 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TOMANENG GUEST HOME #3FACILITY NUMBER:
191222099
ADMINISTRATOR:TOMANENG, ESTELAFACILITY TYPE:
735
ADDRESS:10403 GERALD AVE.TELEPHONE:
(818) 366-3428
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 6DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Estela TomanengTIME COMPLETED:
02:45 PM
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On 03/27/24 at 11:25AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver Estela Tomaneng and disclosed the purpose of the visit. Cathleya Azcueta the administrator arrived about fifteen (15) minutes later.

LPA asked for the census, client, and staff files.


A physical tour was conducted at 11:40 AM and observed the following:



The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. There is extra canned goods and two (2) emergency containers in the pantry area leading to the outside/backyard. Under the kitchen sink the knives and chemicals are kept locked and inaccessible to the clients. There is a seven (7) day food menu on the refrigerator. The medication and first aid kit are on the left-side of the kitchen locked and inaccessible to the clients. The washer and dryer are located on the right-side of the kitchen exiting a door that has access to the backyard. The telephone line is located on the kitchen counter.

Outside/Backyard: The outside/backyard has furniture for the clients with proper seating. The facility does not have a signal system. The facility does have a pool that is currently empty, locked, and inaccessible to the clients. The outside/backyard can be accessed from the dining/living room area. There is another refrigerator with food in the backyard.

LIC 809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: TOMANENG GUEST HOME #3
FACILITY NUMBER: 191222099
VISIT DATE: 03/27/2024
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There is a garage that is detached which contains extra toilet paper, orange juice, water, and forks. The garage can be accessed from the front entrance of the facility.

Bedrooms: There are four (4) bedrooms and two (2) full bathrooms. All three (3) bedrooms are shared two (2) clients each. There is also a staff room. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry, grab bars and non-skid mats. The bathroom temperatures of the water are within regulations reading at 110–111-degree Fahrenheit.

The dining/living room area has enough seating for the clients and the staff. The dining room area has a television and internet access. The fire extinguisher is located against the wall on your right-hand side. It is fully charged. The expiration date is 05/2024.

The house temperature is at 73-degree Fahrenheit.

There are several smoke detectors/carbon monoxides in the dining/living area that are operable.



Administrative: There is no annual fee that is due right now. At the entrance of the facility on your left-hand side there is door with extra PPE items. Administrator License, Yes, Emergency/Disaster Plan, Client Grievances, Home Rules and Rights of Individuals with Developmental Disabilities. The surety bond is updated. The fire drill was conducted February 10, 2024.

An exit interview was conducted, no citation(s) 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: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
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