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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222099
Report Date: 08/19/2023
Date Signed: 08/19/2023 03:53:11 PM

Document Has Been Signed on 08/19/2023 03:53 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 #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:
08/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Estela Tomaneng - AdministratorTIME COMPLETED:
04:00 PM
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An unannounced, One (1) year required visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with administrator Estela Tomaneng and explained the purpose of the visit. This facility is a North Los Angeles Regional Center vendored facility Level II.

A tour of the physical plant was conducted at 12:44 PM and the following were noted:

The facility has three (3) shared client bedrooms and two (2) bathrooms. An additional bedroom and one (1) bathroom is designated for staff use. The swimming pool is appropriately fenced and empty during the time of visit.

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.

Bedrooms were toured and observed to be clean and furnished.
Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured was measured at 114.4°F. (continued to LIC 9099-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2023
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 #3
FACILITY NUMBER: 191222099
VISIT DATE: 08/19/2023
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions and poisons are locked in the cabinet below the kitchen sink. Laundry area is located adjacent to the kitchen going to the backyard exit. Laundry soap and other toxins are kept locked in a cabinet in the laundry area,
Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 73.0°F and observed to be within the required range.
Fire extinguisher was observed in the laundry area by the kitchen. Extinguisher was observed to be full and current and last bought on 05/27/23. Smoke alarms were tested and observed to be operational. There are carbon monoxide detectors installed at the facility.
Medications were observed to be locked, inaccessible and stored in the kitchen cabinet. Medication records and procedures reviewed with staff. First aid was observed to be with complete kit and manual.
The Garage is attached to the house but has no access from the inside. The garage is being used as storage for old equipment and PPE. There is a shaded area with furniture in the backyard.

Client records: All six (6) clients records were reviewed. Client records appeared to be complete and updated.

Staff records were also reviewed. All staff have criminal record clearances and associated to this facility.
Current training and first aid/CPR observed for staff on duty. Administrator's certificate observed to be current.

Disaster drill was last conducted on 05/29/23. Required posting (complaint hot line poster, LTCO, etc) were observed posted in the facility

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: 08/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2023
LIC809 (FAS) - (06/04)
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