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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850376
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:34:08 PM

Document Has Been Signed on 07/23/2024 03:34 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:EMPOWER RESIDENTIAL WELLNESS CENTER LLCFACILITY NUMBER:
195850376
ADMINISTRATOR/
DIRECTOR:		DAHLMANN, MARIAFACILITY TYPE:
772
ADDRESS:6603 BELLINGHAM AVETELEPHONE:
(818) 209-5011
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 0DATE:
07/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Thomas McNulty, ApplicantTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an announced Prelicensing and Component III visit using the complete CARE Inspection Tool. LPA Yee met with Thomas McNulty, Applicant. Also participating in today's visit were Maria Dahlmann, Designated Administrator, Barbara Kimberling, Regional Program Director, Matthew Longoria, Compliance, Darren Longnecker, IT, and Shawn Mokricky, Maintenance.

The facility is a single storey family home consisting of a dining room, front room, a kitchen, a living room, four bedrooms of which one is designated as an office, a common bathroom and a private bathroom located in the bedroom identified as room #4. Located in the back is a separate building with a separate address of 12207 Kittridge Street. No bodies of water observed on the property. The facility is fire cleared for 6 AMBULATORY clients.

The following were observed on today's visit:
  • the front room is furnished with a chair, shelf, a desk and 2 chairs. Located in the front room is also a wood burning fireplace that will be closed off with plexiglass. A fire extinguisher that was last serviced on 3/13/24 was also observed
  • the dining room is furnished with a long table and 8 chairs
  • the kitchen is equipped with a refrigerator, stove, dishwasher, microwave, coffee maker. Sufficient dinner plates, cups, utensils and pots and pans were observed. There were no perishables purchased and insufficient non-perishable foods for a minimum of 7 days were observed
  • the living room is furnished with a L-section sofa, armchair and a wall mounted television. Located in the living room is a second fire extinguisher also serviced on 3/13/24.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 3
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: EMPOWER RESIDENTIAL WELLNESS CENTER LLC
FACILITY NUMBER: 195850376
VISIT DATE: 07/23/2024
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  • All 3 resident bedrooms are furnished with 2 beds, 2 chairs, 2 night stands, 2 lamps, 2 dressers and a shared closet.
  • All resident beds were observed with a mattress cover, fitted sheet, flat sheet and a bed cover. No blankets were observed.
  • all the facility windows were observed with blinds in good repair
  • 16 bath towels, 18 wash clothes and an extra set of bed linens were observed in the linen closet located in the hall way. No hand towels were observed
  • hygiene products were observed in the office
  • first aid kit was reviewed and a tweezer, thermometer and scissors were observed.
  • the office is furnished with a desk, a chair and cabinets. Medications and sharp knives will be stored in the locked closet and cleaning solutions will be stored in a locked cabinet.
  • the laundry room was observed by bedroom #4 and is equipped with a washer and dryer.
  • the common bathroom is equipped with a toilet, bath tub with a shower, 2 sinks a non-skid mat and no grab bars. The water was tested and read 119.6 degrees Fahrenheit
  • the private bathroom is equipped with a toilet, 2 sinks, a walk in shower stall and a tub. Non-skid mat was observed and no grab bars. Water temperature was tested and read 119.8 degrees Fahrenheit
  • the hardwired combination smoke/carbon monoxide detectors were tested and were operational
  • per the Applicant, the facility has liability insurance with limits of 2 million per occurrence and 4 million total annual aggregate.
  • the facility uses cameras in the common areas. A camera was observed in the dining room, front room, living room and the office. The facility also uses 5 cameras outside the home.
  • the backyard is furnished with a picnic table with benches that needs an umbrella for shade. There is also a table with 3 chairs under the covered patio.
  • Trash cans were observed on the street due to trash pick up day. Trash cans looked to be in good condition.
  • Gates were observed along the right side of the home and behind the home and were not locked from the inside.
  • The building with the separate address behind the facility is used solely for storage and not part of the facility operations. The building would have to be licensed prior to use.
  • The front and back yard were observed to be cleaned.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: EMPOWER RESIDENTIAL WELLNESS CENTER LLC
FACILITY NUMBER: 195850376
VISIT DATE: 07/23/2024
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The following corrections need to be made prior to licensure:
  • blankets need to be purchased for all the beds
  • perishable foods need to be purchased prior to accepting the first clients. Non-perishable foods need to be supplemented.
  • hand towels need to be purchased in quantities that will allow for changing
  • a labor poster needs to be posted.
  • provide a copy of the liability insurance.
  • an umbrella needs to be purchased for the picnic table located in the backyard.
  • purchase a first aid manual (ordered during the visit)

Applicant will notify LPA once the corrections are completed.

Component III was conducted with Thomas McNulty, Matthew Longoria and Shawn Mokricky.


Exit interview was conducted.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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