195850238-3-18-2022-29-AS-BBAI-CCMQL7-20220318121528

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850238
Report Date: 03/18/2022
Date Signed: 03/18/2022 12:16:30 PM

Document Has Been Signed on 03/18/2022 12:16 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:	BAGET'S HOME		FACILITY NUMBER:	195850238
ADMINISTRATOR:	BAGET, BADUNG DAVOU		FACILITY TYPE:	735
ADDRESS:	7524 WISH AVE		TELEPHONE:	(818) 518-4635
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 3		CENSUS: 0	DATE:	03/18/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Badung Baget -		TIME COMPLETED:	12:30 PM

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 Analyst (LPA) Brian Balisi conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Badung Baget. This is a new Adult Residential facility. This is a Regional Center Level 4 home. The facility is One story. At 10am , a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for (2) non-ambulatory residents; (1) ambulatory residents; and, (0) bedridden residents. The facility has (4) private bedrooms, Room #1 is approved for Non – Ambulatory and has a direct exit to the outside. Rooms #2 and 3 are both private and do not have a direct exit to the outside. Room #4 is a designated staff room and LPA observed it to be empty at this time. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. There are (2) bathrooms in the hallway. Bathroom #3 is designated as a staff restroom; The resident bathroom #2 has a shower with non-skid materials and mat. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Continued on 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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: BAGET'S HOME	FACILITY NUMBER: 195850238
	VISIT DATE: 03/18/2022

NARRATIVE

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Continued from 809

Resident and staff records are stored in the file cabinet, which is currently located in the office area. Medications are to be centrally stored in a locked cabinet to the right of the front door. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were located in the locked cabinet in the kitchen.

Kitchen knives and sharp objects are stored in a locked box , in a locked cabinet to the left of the kitchen sink. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F.The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located under the sink. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is screened and there are no tools. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are (2) fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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: BAGET'S HOME	FACILITY NUMBER: 195850238
	VISIT DATE: 03/18/2022

NARRATIVE

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Continued from 809-C

Hot water was tested in each bathroom, which included the resident bathroom(s) and any common bathrooms, in addition to the kitchen; and, the hot water ranged from 112 to 113 degrees Fahrenheit. The laundry area is located in the backyard. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a linen closet by room #2 Extra incontinence supplies are stored in the linen closet as well. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout. The emergency telephone numbers are posted on a bulletin board above the fire place. Other required postings are posted near the entry and above the fire place.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The property is fenced on the right side of the home. The back and sides of the house are separated from the front yard by gates at the East and West side passageways. The gate to the driveway on the right side of home is moved manually. There is a door w/gate with a self-latching mechanism for persons to enter the back yard. There are (3) locked storage shed in the back yard. LPA observed each to store either extra medical supplies, food and furniture. There are no bodies of water on the premises at the present time There is no garage on site.

Component III was conducted in conjunction with the visit.

No corrections required on a pre-licensing visit at this time. Exit interview conducted. Report issued and sent via email.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC809 (FAS) - (06/04)

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