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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290890
Report Date: 04/21/2025
Date Signed: 04/21/2025 04:59:31 PM

Document Has Been Signed on 04/21/2025 04:59 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 HOMEFACILITY NUMBER:
191290890
ADMINISTRATOR/
DIRECTOR:		BLAKE, CATHERINEFACILITY TYPE:
735
ADDRESS:606 JACKMAN AVENUETELEPHONE:
(818) 361-1984
CITY:SAN FERNANDOSTATE: CAZIP CODE:
91340
CAPACITY: 6CENSUS: 5DATE:
04/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Jannie Blake - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Annual Required visit and inspection of the facility. LPA met with staff, Jannie Blake and explained the reason for the visit.

The facility is a two story building with 5 bedrooms and 2 bathrooms. The fifth bedroom is upstairs and includes a full bathroom; the second floor is not included on the facility sketch. The administrator will submit an updated sketch to include all rooms on both floors. The facility has an approved fire clearance for 6 ambulatory clients; current census is five (5).


LPA spoke with Administrator - Samuel Blake, who stated that is unable to visit the facility today but he designated Jannie Blake-Care giver to sign the report. At 10:45am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the kitchen. The smoke alarms are hardwired and interconnected. The carbon monoxide/smoke detectors were tested to be functioning properly. The fire extinguisher is located in the kitchen and has a charge date of 09/12/2025.

Kitchen: LPA observed a refrigerator, stove, microwave oven, dishwasher and laundry machines in the kitchen. Sharp objects were locked in a cabinet in the kitchen and cleaning solutions and detergents were locked under the sink. There is a large supply of dishes in the cabinets. Facility has perishable foods for two (2) days in the refrigerator. LPA observed two additional freezers and a refrigerator in the garage, with perishable foods for two (2) days in the garage refrigerator, freezers and cabinets. A supply of non- perishable foods for seven (7) days were kept in the garage as well. Facility keeps a supply of detergents and chemicals in the garage cabinet, separate from the food supplies.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/21/2025
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Bedrooms/Bathrooms: The facility has five (5) bedrooms in total. The bedroom on the second floor is a staff bedroom, with it's own full bathroom but is currently vacant. There are stairs with a chair lift leading to bedroom upstairs. On the first fllr, there is a full bathroom at the end of the hallway, which is utilized by residents. The water temperature at the resident bathroom was measured at 120.7 degrees Fahrenheit. There are three (3) shared bedrooms. All bedrooms contained a chair, night stand, dresser or storage, lamp, and beds with adequate bedding. The bedroom on the northeast corner of the facility is designated as an office/staff room and it has it's own bathroom. The resident and staff files are kept locked in the office/staff room.

Common Areas: These included the dining area in kitchen, living room, dining area and recreation room. There is a screened fireplace in the recreation room; in addition there are games, newspapers, television, cable and internet access. The common areas were properly furnished with ample seating for all residents and staff.



Surrounding Grounds: The main entry door is used for the emergency exit. In addition the facility has an exit door in the kitchen and a door in the recreation room, leading to the side exit. All walkways and exit passages were free of obstruction. There is a covered patio with ample furniture appropriate for outdoor
use. The outdoor area was clean and free of hazards. No bodies of water were observed. There is an attached garage, currently used as storage.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliant with licensing forms.

Medications: Medication and Medication Records were reviewed for proper documentation and administration.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
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