<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850275
Report Date: 07/29/2022
Date Signed: 08/02/2022 09:39:14 AM

Document Has Been Signed on 08/02/2022 09:39 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:GAULT HOMEFACILITY NUMBER:
195850275
ADMINISTRATOR:HASTINGS, SUZIEFACILITY TYPE:
735
ADDRESS:12706 GAULT STREETTELEPHONE:
(818) 759-1252
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 4CENSUS: 4DATE:
07/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Suzie HastingsTIME COMPLETED:
01:00 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
On 07/29/2022, the pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 10:00 a.m., and met with applicant Suzie Hastings. This is a Change of Ownership (CHOW) application for an Adult Residential Facility for three (3) ambulatory residents, and one (1) non-ambulatory resident.

At 10:30 a.m., the LPA, and the applicant toured the physical plant areas inside and outside to ensure there
are no health and safety hazards, and that facility is in compliance with Title 22 Regulations.

KITCHEN: A seven day supply of non-perishable food was available. The supply of dishes is adequate.
Appliances in the kitchen were clean and all appeared functional. Kitchen, and house cleaning supplies are
stored in locked cabinet in the garage area. Hot water temperature was recorded at 114.2 degrees
Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides, or toxins stored near food, or
preparation area.

BEDROOMS: There are three bedrooms for residents use, one room has double occupancy and two bedrooms have single occupancy. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing and personal belongings.

BATHROOMS: The bathrooms are fully stocked with paper towels and hand soap. The shower has non-skid
surface/mat. Hot water temperature was recorded at 112.6 degrees Fahrenheit. Hand washing signs were visibly posted in each bathroom.

Continues on LIC 809-C...
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: GAULT HOME
FACILITY NUMBER: 195850275
VISIT DATE: 07/29/2022
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
26
27
28
29
30
31
32
COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There
are televisions and other entertainment equipment in the living room area. Residents and staff records, along with medications will be stored in a closet located in the hallway leading to the bedrooms. The first aid supplies were complete, including a thermometer, and a current version of a first aid manual, and is located in the common area of the living room.

The facility’s smoke/carbon monoxide alarm systems are hard wired. All rooms were tested, and all smoke/carbon monoxide alarm systems were in operating condition. A fire extinguisher is properly charged and is located mounted on the wall in the kitchen area. The laundry area is located in the garage area. The supply of extra bed and bath linens is adequate. There is a functioning land line telephone on the premises. Infection control, and other posters are posted throughout the facility, and hallways.

The exterior passageways were clean, and clear of any obstructions. The patio is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for residents and visitors. Fire emergency gates are clear of obstructions.

The applicant completed Component III Orientation.

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.

Exit interview was conducted, and reviewed with applicant Suzie Hastings. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2