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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850276
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:17:18 PM

Document Has Been Signed on 08/22/2024 12:17 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:WILKINSON HOMEFACILITY NUMBER:
195850276
ADMINISTRATOR/
DIRECTOR:		HASTINGS, SUZIEFACILITY TYPE:
735
ADDRESS:7719 WILKINSON AVETELEPHONE:
(818) 764-3004
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 4CENSUS: 3DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:59 AM
MET WITH:Suzie HastingsTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 08:59 AM. LPA contacted the facility administrator Suzie Hastings via telephone call. Facility administrator arrived to the facility at 09:18 AM Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:20 AM, the LPA, along with facility 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. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. The LPA observed the fire extinguisher to be fully charged and purchased on 05/09/2024. The water temperature was measured at 119 degrees Fahrenheit, which is in compliance with regulation.

BEDROOMS: There are three (3) bedrooms in the facility; all are designated for resident use, and one (1) designated as a dual occupancy room. LPA and facility administrator toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a resident restroom and one (1) is designated as a staff restroom. Both bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in the resident shower and was properly secured. The water temperature was measured in both bathrooms at 120.3 degrees Fahrenheit. Report Continued on LIC 809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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 4
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: WILKINSON HOME
FACILITY NUMBER: 195850276
VISIT DATE: 08/22/2024
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COMMON AREAS: This includes the living room and dining room. LPA observed the living room to be clean and properly furnished at the time of the visit. Smoke detectors and carbon monoxide detectors were tested at 09:34 a.m. and were functional at the time of the visit. The dining room contains adequate seating for resident use. The dining room contains an appropriately screened fireplace.

OUTDOOR SPACE: The facility has one (1) emergency exit gate, LPA observed clear passageways for emergency exit use. The facility has adequate seating for resident use. There is currently ongoing construction in the back yard of the facility on a separate property with a separate address. LPA observed one (1) secured shed to contain a washer and dryer as well as emergency water and cleaning supplies.

RECORD REVIEW: Record review began at 09:50 a.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, TB tests, consent forms, and personal rights. Six (6) staff files were reviewed. All staff files contained the required documents and trainings. Three (3) resident files were reviewed. All resident files reviewed contained all required documentation. No deficiencies were observed during record review.

MEDICATION REVIEW / CASH RESOURCE REVIEW: Medication review began at 10:50 a.m. Medications are stored centrally and securely in the administrator’s office. Medications for two (2) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. Cash resources were reviewed for one (1) resident, all cash resources observed were documented properly with the corresponding receipts. No deficiencies were observed during cash resource review.

INFECTION CONTROL / EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 05/28/2024. The facility’s emergency disaster plan is up to date and adequate.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: WILKINSON HOME
FACILITY NUMBER: 195850276
VISIT DATE: 08/22/2024
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INTERVIEWS: LPA was unable to interview staff or residents. Residents were away at their day program and the only staff available was the administrator, Suzie Hastings.

During today’s visit LPA obtained a copy of the facility’s updated LIC500, resident roster, surety bond, and liability insurance.

No deficiencies were cited at the time of the visit. Exit interview conducted. And a copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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