195850275-8-8-2023-29-AS-SURA-CUJ5D8-20230808195128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850275
Report Date: 08/08/2023
Date Signed: 08/08/2023 07:52:39 PM

Document Has Been Signed on 08/08/2023 07:52 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:	GAULT HOME		FACILITY NUMBER:	195850275
ADMINISTRATOR:	HASTINGS, SUZIE		FACILITY TYPE:	735
ADDRESS:	12706 GAULT STREET		TELEPHONE:	(818) 759-1252
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 4		CENSUS: 4	DATE:	08/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Suzie Hastings		TIME COMPLETED:	03:10 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) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection at 10:10 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Suzie Hastings arrived shortly thereafter. At 10:30 a.m., the LPA, and the administrator 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 th 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 809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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: GAULT HOME	FACILITY NUMBER: 195850275
	VISIT DATE: 08/08/2023

NARRATIVE

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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 are 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 storage 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.

OUTDOOR AREA: 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.

RECORDS: Records review began at 12:00 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training reuqired. All files were in order.

MEDICATIONS: Medications review began at 12:35 p.m.; medications are centrally stored and locked in closet, medications were labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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