195850276-8-9-2023-29-AS-SURA-CUJVZZ-20230809165335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850276
Report Date: 08/09/2023
Date Signed: 08/09/2023 04:54:14 PM

Document Has Been Signed on 08/09/2023 04:54 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:	WILKINSON HOME		FACILITY NUMBER:	195850276
ADMINISTRATOR:	HASTINGS, SUZIE		FACILITY TYPE:	735
ADDRESS:	7719 WILKINSON AVE		TELEPHONE:	(818) 764-3004
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 4		CENSUS: 2	DATE:	08/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Suzie Hastings		TIME COMPLETED:	02:00 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	Licensing Program Analyst (LPA), Sandra Urena arrived at the facility unannounced to conduct a required annual inspection and met with the administrator Suzie Hastings and explained the reason for the visit. At 9:30 a.m., the LPA, and the administrator toured the physical plant areas inside and outside to ensure thereare no health and safety hazards, and facility is in compliance with Title 22 Regulations. KITCHEN: A seven-day supply of non-perishable food was available. The emergency supply is stored in the laundry room. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen, and house cleaning supplies are stored in a locked cabinet next to the dining room area. Hot water temperature was recorded at 112.2 degrees Fahrenheit. There were no pesticides or toxins stored near food, or preparation area. BEDROOMS: There are three bedrooms for resident use, two rooms are shared rooms and one single room. Lighting in the rooms appeared adequate. There is one staff room. All bedrooms had adequate closet and drawer space for clothing and personal belongings. The supply of extra bed and bath linens is adequate. Continues on LIC 809-C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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: WILKINSON HOME	FACILITY NUMBER: 195850276
	VISIT DATE: 08/09/2023

NARRATIVE

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BATHROOMS: The bathroom is fully stocked with paper towels and hand soap. The shower has non-skid
surface. Hot water temperature was recorded 113.5 degrees Fahrenheit. Hand washing signs were visibly
posted in each bathroom.

COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There
Is a television 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 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 a shed in the backyard area. There is a functioning land line telephone on the premises. Infection control, and other posters are posted throughout the facility and hallways.

OUTDOORS: 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 10:00 a.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. All files were in order.

MEDICATIONS: Medications review began at 10:30 a.m., medications are centrally stored and locked, medications are 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.

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

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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