191290890-4-12-2024-31-AS-AAEA-D49W46-20240412165702

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191290890
Report Date: 04/12/2024
Date Signed: 04/12/2024 04:57:27 PM

Document Has Been Signed on 04/12/2024 04:57 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BLAKE HOME		FACILITY NUMBER:	191290890
ADMINISTRATOR/ DIRECTOR:	BLAKE, CATHERINE		FACILITY TYPE:	735
ADDRESS:	606 JACKMAN AVENUE		TELEPHONE:	(818) 361-1984
CITY:	SAN FERNANDO	STATE: CA	ZIP CODE:	91340
CAPACITY: 6		CENSUS: 6	DATE:	04/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Administrator, Samuel L. Blake Jr.		TIME VISIT/ INSPECTION COMPLETED:	04:40 PM

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At 1:40 p.m. on 04/12/2024, Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced annual inspection. LPA met with Administrator and explain the reason for the visit. Administrator and LPA toured the facility inside and out.

The facility was last inspected on 04/06/2022 for an annual inspection. It is a two story building with 5 bedrooms, 2 bathrooms, kitchen, nook, living room, recreation room, dining room, storage closets, garage, front and back yard. The fifth bedroom is upstairs and is not included on the facility sketch. The facility has an approved fire clearance for 6 ambulatory clients.

Record Reviewed: LPA reviewed files for clients and staff regularly scheduled at the facility. Client files were reviewed for admission agreements, medical assessments, appraisals, consent forms and medication records. During a review of records with the Administrator, it was observed that the last disaster drill was conducted on 11/15/2023.

Bedrooms: The facility has 5 bedrooms in total. The bedroom on the second floor is a staff bedroom. The bedroom on the northeast corner of the facility is designated as a staff office. The staff bedroom and staff office were locked. All other rooms are client shared bedrooms. All lights where working and furniture was clean and in good repair.

Bathrooms: LPA inspected the bathroom designated for clients it has toilet paper, and a hand blower. All fixtures are clean and in great working condition. At 2:00p.m. LPA measured the water temperature to be 116.2 degrees Fahrenheit.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLAKE HOME	FACILITY NUMBER: 191290890
	VISIT DATE: 04/12/2024

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Kitchen: Sharp objects were locked in a cabinet to the right of the sink. Cleaning solutions and detergents were locked under the sink. The exhaust hood was clean. All surfaces were free from debris. Two laundry machines were operational and next to the kitchen.

Nook: LPA observed 1 table and 6 chairs. Postings on a bulletin board included the personal rights, confidential complaint information, house rules, emergency disaster plan, and a weekly menu.

Common areas: Walls, floors, ceilings, blinds, and window screens were all in good condition. LPA also saw a house telephone and board games available. At approximately 2:10 p.m. the room temperature was measured at 73 degrees Fahrenheit. The facility has a light in the hallway with motion sensors. LPA observed two storage closets with linens and bedsheets. Staff informed LPA that a cleaning crew comes twice each month when clients are not at the facility.

Outdoor area: LPA observed a floodlight and a covered patio area. All furniture was in good condition. The back yard was maintained.

Garage: The garage was locked. Access is maintained by remote control. LPA observed 3 freezers and 1 refrigerator in the garage. They contained adequate supplies of perishable and non-perishable food. LPA also observed more non-perishable food stored on shelves. In cabinets, LPA observed toxins, paint, paper supplies, and cleaning solutions. They were stored separate from food.

Safety: Emergency exit paths were clear and free from hazards. The exit gate to the front yard was unlocked. Exit door in the front were locked from the outside but unlocked from the inside. At 2:20 p.m. the smoke detector and carbon monoxide was tested to be functional. LPA observed a fire extinguisher hung in the kitchen and fully charged.

During today's visit, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report was provided to Administrator.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC809 (FAS) - (06/04)

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