195850321-3-15-2023-29-AS-AASO-CPXQGG-20230315120930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850321
Report Date: 03/15/2023
Date Signed: 03/15/2023 12:10:37 PM

Document Has Been Signed on 03/15/2023 12:10 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:	OPI STR		FACILITY NUMBER:	195850321
ADMINISTRATOR:	FIGUEROA, PAUL		FACILITY TYPE:	772
ADDRESS:	6123 WOODLAKE AVE		TELEPHONE:	(818) 572-0607
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 0	DATE:	03/15/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Paul Figueroa		TIME COMPLETED:	12:25 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) Angel Ascencio conducted a pre-licensing visit to the above noted facility. The LPA met with applicants, Jessica Breton, Susan Warren and Paul Figueroa. This is a new facility. The facility is two-story home. At 10:05 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) ambulatory clients only. First Floor: The facility has three (3) bedrooms, all of which are shared. No client rooms have direct exits to the outside. All client rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms – ‘awake night staff only’. All rooms were free of odors. All window screens were clean and maintained in good repair. There is one (1) bathroom in the hallway for client use. One (1) is designated as a staff bathroom. Room # 1 has a shared bathroom. The client and hallway bathrooms have a shower with non-skid materials. The toilet and showers have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Client and staff records will be stored in a locked filling cabinet, which is currently located in Nurse's Station. Medications will be centrally stored in a locked cabinet in the Nurse's Station. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in the medication room. Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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: OPI STR	FACILITY NUMBER: 195850321
	VISIT DATE: 03/15/2023

NARRATIVE

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Kitchen knives will be stored in a locked drawer in the kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies will be stored in a locked cabinet located in the kitchen and the garage. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non private bathrooms. The stairway leading to the second floor is equipped with sturdy, hand railings. There are various fireplaces at the home. They are all screened and there are no tools accessible. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that clients occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are four (4) fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date. The laundry room, was observed locked, and is located near the garage. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a hallway closet. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the common hallways. The emergency telephone numbers are posted in the common hallway and Nurse's Station. Other required postings are posted at the common hallway.

Second Floor:

Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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: OPI STR	FACILITY NUMBER: 195850321
	VISIT DATE: 03/15/2023

NARRATIVE

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The second floor consisted of various office spaces which will be used for therapy sessions and entertainment. Additionally, a staff office and staff restroom was observed.

Exterior:

The exterior passageways were clean and clear of any obstructions. There is an awning, covered patio area at the back of the house with tables and chairs where clients can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by a gate at the south side passageway. There is a door with a gate, with a self-latching mechanism for persons to enter the front yard. There is a locked storage shed in the south side of the home. There are two (2) bodies of water on the premises at the present time, which were rendered inaccessible. One (1) is a pool, the other is a jacuzzi. The garage is accessible from the house; the doors were locked.

Pre-Licensing is complete and this facility has no deficiencies.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. 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.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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