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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222779
Report Date: 08/29/2022
Date Signed: 08/29/2022 12:37:56 PM

Document Has Been Signed on 08/29/2022 12:37 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:DESTAJO'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
191222779
ADMINISTRATOR:DESTAJO, CRISTINAFACILITY TYPE:
735
ADDRESS:9938 SWINTON AVETELEPHONE:
(818) 893-5123
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 6DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Teresa BatitisTIME COMPLETED:
12:30 PM
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LPA Spaeth conducted an unannounced visit to the facility and was greeted by caregiver/house manager. LPA stated the purpose of the visit was to conduct an annual visit. Caregiver confirmed there are six residents at the facility. LPA observed both caregivers were wearing a mask, LPA's temperature was recorded and COVID questions were answered by LPA. The caregiver confirmed there are four resident rooms, a staff room, and two bathrooms.

When LPA entered the family room, LPA observed four residents watching television and participating in a drawing activity. LPA and the caregiver began the tour at 11:30 am. LPA observed the staff room was locked. Upon entering the staff room, LPA observed the cleaning supplies, laundry soap, and PPE supplies were located in a closet. LPA was escorted to the kitchen and observed the resident medications were locked in a kitchen cabinet. The cabinet underneath the sink was locked and contained cleaning supplies. The refrigerator contained a four-day supply of fresh fruits, fresh vegetables, and dairy products. The pantry contained a seven- day supply of canned goods and other non-perishable items. LPA also observed the knives were safely locked within the facility. The laundry area contained the washer and dryer and the cabinets within the room were empty.

LPA observed the resident rooms and all rooms contained bed, linens, night stand, night lamp, and closet. The resident bathroom contained slip resistant mat in the shower, wash your hands sign, hand soap, paper towels, and a trash can. A locked closet in the resident bathroom contained hygiene items, adult diapers, and additional PPE items. The staff bathroom contained wash your hands sign, hand soap, paper towels, and a trash can. LPA observed the facility was neat and clean. LPA observed the backyard and the swimming pool was secure with a locked gate. The outside side gate was not locked and a shaded area with seating was available for the residents. There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the report was given to the caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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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