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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850156
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:00:40 PM

Document Has Been Signed on 07/25/2022 03:00 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CNS QUAKERTOWNFACILITY NUMBER:
195850156
ADMINISTRATOR:MARC SAINT CLAIRFACILITY TYPE:
735
ADDRESS:5135 QUAKERTOWN AVENUETELEPHONE:
(661) 872-3408
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY: 6CENSUS: 5DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Marc Saint ClairTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 1:15 p.m. This will be the first Annual from their Pre-Licensing visit on 6/22/2021. The LPA was scanned and greeted at the door by Administrator, Marc Saint Clair and was explained the reason for the visit. Entrance interview.

At 1:50 p.m., the LPA along with Administrators, Marc and Jacqueline, began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The LPA observed two (2) refrigerators with a sufficient supply of perishable and non-perishable food. The LPA observed knives and sharps in a drawer next to the sink locked and inaccessible to residents.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: There are five (5) resident bathrooms. The bathrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. Bathrooms were measured for hot water, temperatures measured between 105.8 and 118.6-degrees Fahrenheit.

…Continued on LIC 809C…

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CNS QUAKERTOWN
FACILITY NUMBER: 195850156
VISIT DATE: 07/25/2022
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...Continued from LIC 809...

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. Cleaning supplies and chemicals are stored and inaccessible to residents. There is a patio area with patio furniture including a table and chairs for resident use. The LPA did not observe any obstructions to emergency exit pathways. No large bodies of water accessible to residents at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed Medications locked in cabinets adjacent to the living room.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings at the time of visit. If needed, the facility has the capacity to self-isolate residents if the facility has a confirmed case of COVID-19.

The LPA and Administrator discussed staff vaccination requirements. All staff are fully vaccinated with the exception of one (1) staff, which facility has exemption on file. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted. No citations issued. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC809 (FAS) - (06/04)
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