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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290706
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:23:15 AM

Document Has Been Signed on 08/03/2023 10:23 AM - 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:HAMILTON HOUSEFACILITY NUMBER:
191290706
ADMINISTRATOR:PETERSON, JANICEFACILITY TYPE:
735
ADDRESS:739 W. GLENOAKS BLVD.TELEPHONE:
(818) 502-9188
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY: 11CENSUS: 5DATE:
08/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nicole IsabeloTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit, in conjunction to complaint and control # 31-AS-20230725081427. Upon investigation, it was revealed to LPA by Administrator Carlos Correa, who is apparently in charge of the facility at this time, that he would be off work for the next couple of days, and the designee in charge was on medical leave. During today's visit, LPA determined the facility did not have the appropriate staff in charge to run the facility, and Administrator David Correa reported the facility are currently having staffing issues. LPA conduced a physical plant inspection and reviewed resident and facility documents, and LPA observed a portable bed in the common area; the living room. LPA inquired about the bed, and clients reported to LPA that the bed is used for overnight staff.

LPA will be issuing citation for lack of appropriate staff/or designee of the facility, and facility having staff sleep in common areas.

Citation issued, exit report issued, appeal rights and copy of report provided.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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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Document Has Been Signed on 08/03/2023 10:23 AM - It Cannot Be Edited


Created By: Tuesday Cabiness On 08/03/2023 at 09:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAMILTON HOUSE
FACILITY NUMBER: 191290706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties...(a) All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute...This requirement was not met, evidenced by, based on visit, LPA was
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Administrator must submit in writing a current staff schedule and new designee in charge when he is not available at the facility.
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informed the Administrator was not available and the designee was on medical leave. Administrator also reported there are current staffing issues. This is a potential health and safety requirement to clients in care.
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Type B
08/10/2023
Section Cited
CCR87307(a)

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87307 Personal Accommodations and Services...(a)...The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility...This requirement was not met, evidenced by, based on physical plant
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Administrator must remove bed in the living room, and provide accomodations for staff that are working.
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inspection. LPA observed a portable bed in the front living room. Clients informed LPA, overnight staff sleep in the living room. This is a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023


LIC809 (FAS) - (06/04)
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