195850275-8-14-2024-29-AS-TBYE-D85V96-20240814161349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850275
Report Date: 08/14/2024
Date Signed: 08/14/2024 04:14:12 PM

Document Has Been Signed on 08/14/2024 04:14 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GAULT HOME		FACILITY NUMBER:	195850275
ADMINISTRATOR/ DIRECTOR:	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:	08/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:06 PM
MET WITH:	Suzie Hastings		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

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Licensing Program Analysts (LPAs) Trevor Byrne and Erica Mosely arrived at the facility unannounced to conduct a required annual visit at 02:06 PM. LPAs met with facility staff who contacted administrator Suzie Hastings via telephone. Administrator arrived at 02:30 PM. LPAs explained the reason for today's visit. Entrance interview conducted.

Beginning at 02:30 PM, the LPAs, along with facility administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: Knives are stored in a locked drawer. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. The fire extinguisher was observed to be fully charged and last serviced on 05/09/2024.

BEDROOMS: The LPAs observed three (3) client bedrooms, all of which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. One (1) client bedroom is designated as a shared bedroom.

RESTROOMS: LPAs observed two (2) resident restrooms. Both are clean and sanitary and in operating condition. Hot water was checked in both restrooms and measured between 105.5 and 108 degrees Fahrenheit. Both were measured within the required range. Showers were observed to contain non-slip surfaces and mats. Grab bars were observed in both restrooms.

COMMON SPACES: Living room, tv room, and dining room furniture was observed to be in good condition. The LPA observed all required postings upon entry. A properly screened fireplace was observed in the living room. Medications were observed to be in a locked cabinet located within the hallway near the entrance to the facility. Fire alarms were tested at 02:46 PM and were functional at the time of the visit. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GAULT HOME	FACILITY NUMBER: 195850275
	VISIT DATE: 08/14/2024

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OUTDOORS: LPAs toured outdoor areas. Tables and chairs were observed with appropriate shading. A shed was observed to be locked. The facility has an emergency exit gate that was free from obstruction.

LAUNDRY: The laundry room contained adequate emergency food and water supplies. LPAs observed a locked cabinet that was utilized to store cleaning chemicals. A first aid kit was observed to be appropriately supplied.

MEDICATION REVIEW: Beginning at 03:20 PM, LPAs reviewed medications for four (4) clients. All medications reviewed were documented and stored in compliance with regulation.

FILE REVIEW: LPAs reviewed files for six (6) staff members. All staff files contained all required documents. Staff training, including 1st aid / CPR, was up to date. LPAs reviewed four (4) resident files for documents including but not limited to: Admission agreement, medical assessment, TB test, and safeguards for cash resources. All records reviewed contained all required documents. LPAs reviewed cash resources for two (2) residents both were properly documented and stored.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPAs reviewed the facility’s emergency disaster plan and infection control plan. The facility’s emergency disaster plan is adequate and reviewed quarterly. The last emergency disaster drill was conducted on 07/07/2024. The facility’s practices as it pertains to infection control are adequate.

INTERVIEWS: During today's visit, LPAs interview two (2) clients no concerns were noted during client interviews. LPAs interviewed two (2) staff members. Both staff understood their roles, clients’ rights, and the forms of abuse as well as the proper reporting procedures.

LPAs obtained a copy of the facility’s LIC500 during today’s visit.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

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