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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222589
Report Date: 05/16/2022
Date Signed: 05/16/2022 02:36:58 PM

Document Has Been Signed on 05/16/2022 02:36 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:HINOJOSA ADULT RESIDENTIAL HOME CAREFACILITY NUMBER:
191222589
ADMINISTRATOR:HINOJOSA, CLAUDIO & OLGAFACILITY TYPE:
735
ADDRESS:10736 STAGG STREETTELEPHONE:
(818) 764-7184
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 4CENSUS: 4DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Carlos Hinojosa TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. Upon entry, LPA was greeted by staff Carlos, who allowed LPA to enter. There have not been any active or past COVID cases at the facility. The current census is (4); all clients and staff are vaccinated, including booster shots. LPA’s temperature was immediately taken and documented; a list of COVID-19 questions was asked; and LPA signed in the visitor book. LPA observed staff to have full mask covering; a hand sanitizing station; PPE supplies at the front door, and COVID-19, and Department of Public Health, and Licensing postings on the walls throughout the facility.

The infection control inspection began with the staff Carlos. The facility has (6) bedrooms; with (2) shared rooms, that were (6) feet apart; and (2) staff rooms. All bedrooms were properly furnished. The common areas were observed to be clean, including bathrooms, with soap and towels. LPA conducted a mitigation plan review with the staff, to obtain information on how the facility has implemented the plan. The Administrator reported to LPA, that everyone vaccinated and have there booster shot. The facility keeps documentation of vaccination and other pertinent information pertaining to COVID-19. All new employee hires and new resident admits, must be properly screened, and vaccinated. Administration continues to conduct training to staff in relation to COVID-19. Administrator reported the facility receives departmental emails. There is paid sick leave policy in place. There are designated rooms for potential positive COVID clients. PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are available.

LPA observed a sufficient supply of all items during the visit. Currently, the facility has sufficient staff, and has back-up staff in place if needed.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HINOJOSA ADULT RESIDENTIAL HOME CARE
FACILITY NUMBER: 191222589
VISIT DATE: 05/16/2022
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The Administrator informed LPA that they continue to implement the best practices for their facility, which has kept them COVID-19 free. The facility is aware to report any changes with clients and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted with Administrator Carlos

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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