195850202-1-19-2022-29-AS-ASMH-CATQVQ-20220119113044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850202
Report Date: 01/19/2022
Date Signed: 01/19/2022 11:31:18 AM

Document Has Been Signed on 01/19/2022 11:31 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PSYCLARITY HEALTH INC.		FACILITY NUMBER:	195850202
ADMINISTRATOR:	BARSALOU, AARON		FACILITY TYPE:	772
ADDRESS:	22550 COLLINS ST		TELEPHONE:	(832) 312-9611
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 0	DATE:	01/19/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Aaron Barsalou		TIME COMPLETED:	11:35 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos arrived at the facility announced at 9:05 a.m. to conduct a pre-licensing inspection. The LPAs met with applicant Aaron Barsalou. The home has the capacity for six ambulatory clients. The fire clearance was granted on 09/08/2021; in which rooms were cleared for ambulatory clients only. The LPAs toured the physical plant areas inside and outside with applicants to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS: Whereas the facility has six (6) rooms, the facility has designated three (3) shared bedrooms for clients. All rooms are set up with beds, nightstands, lamps, chests of drawers and closet space. Client Room #1 has a direct exit to the outside. Client Room #2 and Client Room #3 are located upstairs. Client Room #3 has a direct connection to a small balcony upstairs. Client Room #3 has a fireplace, which is inoperable. Lighting in the rooms appeared adequate. BATHROOMS: In total, there are five full bathrooms and one-half bathroom. Three out of the three client rooms have an attached full bathroom. The client tubs and showers are equipped with nonskid surfaces. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hard wired; the smoke detectors were tested at 9:37 a.m. and were operable at the time of the visit. There are six fully charged fire extinguishers. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted throughout the facility. Other required postings are posted in the laundry room; the LPAs advised the applicant to place the required postings near the entry into the facility.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

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: PSYCLARITY HEALTH INC.	FACILITY NUMBER: 195850202
	VISIT DATE: 01/19/2022

NARRATIVE

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KITCHEN: Kitchen knives are locked and inaccessible. The supply of nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional at the time of the visit. At 10:13 a.m., the hot water temperature was measured at 111 degrees Fahrenheit.

MEDICATIONS: Medications will be in a locked cabinet in the office. The applicant was advised to purchase additional items for the first aid kits; the items were purchased during today’s visit. First aid kits are placed throughout the facility.

THERAPY AND STAFF: The additional three rooms are designated as staff offices. Group and individual therapy can take place in the common spaces, outdoors, and in designated office areas. Staff and client files will be stored electronically. Facility will have awake staff only; there are no staff sleeping quarters on the property.

LAUNDRY: The laundry room is in the hallway. Laundry detergent will be stored inaccessible.

GARAGE AND GROUNDS: The garage is accessible from the house and is kept locked. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs where clients can sit. There is an in-ground pool with appropriate fencing, which is kept locked. There is a single-press door that allows for immediate egress into the exterior of the facility. The facility plans to have an eight passenger van on the premises for transportation use.

INFECTION CONTROL: The facility confirmed that they will have a central entry point for symptom screening and sanitation station for staff, clients and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Component III was conducted with the applicant during today’s visit.

The physical plant of this facility location is in compliance with Title 22 regulations at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC809 (FAS) - (06/04)

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