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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222779
Report Date: 09/27/2023
Date Signed: 09/27/2023 02:39:44 PM

Document Has Been Signed on 09/27/2023 02:39 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: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: 1DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Teresa Batitis & Cristina DestajoTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA) Tuesday Cabiness, Huma Rahimi, Leslie Ngo-Castaneda, and Gina Saucedo arrived at the facility at 9:45 am to conduct an annual inspection. LPA's were greeted by house manager Teresa Batitis, who allowed LPA's to enter. Administrator Christina Destajo arrived at 10:20 am, and everyone was informed the reason of the visit. A complete inspection/tour of the facility was conducted from the inside and outside. The following was observed during the inspection:

Kitchen: LPA's observed Licensing requirement of (7) day nonperishable, and (2) day perishable, with extra refrigerator for staff only and freezer stocked with food, in the office. During observation of food in the freezer there was freezer burns and expired food, therefore technical assistance (TA) was given. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, that are stored in the kitchen and garage area were locked and secured. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (4) bedrooms residents; with (2) room for staff. All bedrooms were properly furnished and supplied with appropriate bedding and linens where two rooms are shared by residents. With total of 5 non- ambulatory residents. There were sufficient linens observed and available. Bathrooms: There are (2); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at 114 degrees Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. But the other side of the exit, according to the administrator the neighbor is responsible with the a fallen fence, the Administrator is currently working with the neighbor to facilitate and fix the fence that is not stable and sturdy towards the exit. The facility has outdoor furniture, with a covered shaded area for residents and visitors. The facility has a swimming pool/body of water that is fence and lock with a padlock. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the staff room. Not all exit doors have locks; all were operating. Fire extinguisher fully charged. First aid kit furnished fully equipped.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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: DESTAJO'S ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 191222779
VISIT DATE: 09/27/2023
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Record review: A complete record review of staff and residents were conducted, all required documents were in file. Medication review: no errors.

Infection/Mitigation Control Review: Upon entry, LPA entered office and there was a sign-in sheet with a cleaning station. Staff were not wearing masks upon entry but put them on during the inspection. Soap and towels, and hand washing signs were visually posted. Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and throughout the facility. The facility has sufficient stock of PPE. The facility has cleaning procedures and protocols in place, which include staff cleaning common areas throughout the day. The facility has documentation of all vaccination records for staff and residents. There are no current staffing issues; during today's visit, LPA observed (2) staff on duty. New clients or new staff must be vaccinated upon entry of the facility. There are designated rooms for potential positive COVID residents. PPE supplies were inspected and have over (30) day supply. The facility continues to implement the best practices for the facility; to ensure the health and safety of residents and staff. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases. Exit interview and copy of report provided office and there was a sign-in sheet with a cleaning station. The facility has documentation of all vaccination records for staff and residents. There are no current staffing issues; during today's visit, LPA observed (2) staff on duty. New clients or new staff must be vaccinated upon entry of the facility. There are designated rooms for potential positive COVID residents.


PPE supplies were inspected and have over (30) day supply. The facility continues to implement the best practices for the facility; to ensure the health and safety of residents and staff. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview and copy of report provided, and technical assistance issued.

Report was amended due to signatures not captured.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC809 (FAS) - (06/04)
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