195850495-9-25-2024-29-AS-CYEE-D9G3FZ-20240925181334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850495
Report Date: 09/25/2024
Date Signed: 09/25/2024 06:13:46 PM

Document Has Been Signed on 09/25/2024 06:13 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:	DOLLY HOUSE		FACILITY NUMBER:	195850495
ADMINISTRATOR/ DIRECTOR:	PIPPARD, JENNIFER		FACILITY TYPE:	735
ADDRESS:	6500 WHITSETT AVENUE		TELEPHONE:	(818) 762-4365
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 6	DATE:	09/25/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Jennifer Pippard, Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:20 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) Christine Yee conducted an announced Prelicensing and Component III visit and met with Jennifer Pippard, Administrator and Corrine Botte, Operations Manager. The facility is single storey family home consisting of a living room, dining room, a kitchen, laundry room, 6 resident bedrooms, an office/medication room, 3 common bathrooms and a conference room with a private bathroom. The facility is fire cleared for 6 NON-AMBULATORY clients. The following were observed on today's visit: the living room is furnished with a sofa, love seat, 2 arm chairs and a stand with a television the dining room is furnished with a long dining room table and 6 chairs. the kitchen is equipped with a stove, 2 refrigerators, 2 dishwasher and a microwave. Plates, bowls, drinking cups, forks and spoons for 6 residents were observed. Pots and pans for cooking. Sufficient perishable foods for a minimum 2 days and insufficient non-perishables for a minimum of 7 days were observed. Knives are stored in a locked drawer the laundry room was observed with a washer and dryer and were operational. Laundry detergent are stored in a locked cupboard. Bedrooms #1, #2, #4, #5 all have a twin bed, #3 has full sized bed and #6 has a hospital bed with full bed rails. Resident is on hospice. All bedrooms contained a night stand, a chair, a dresser, a lamp and a built in closet. Bed linens per personal preference were observed on the bed. Throw blankets were observed on the beds. Full sizes blankets need to be purchased for the residents. Extra flat sheets, fitted sheets, pillow cases, bath towels, hand towels and face towels were observed in the hallway linen closet.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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: DOLLY HOUSE	FACILITY NUMBER: 195850495
	VISIT DATE: 09/25/2024

NARRATIVE

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The bedroom windows were observed with blinds. The window screens were in good repair but could use a cleaning-dusty.
The office/ medication room were furnished with desk, computer, printer for staff use. The medication room is used for medication storage.
All 3 common bathrooms were equipped with a walk in shower, shower bench, grab bars, a single sink, a toilet. No non-skid mats were observed. The water temperature was taken in bathroom #1 read 107.4, water temperature in bathroom #2 read 103.1 and the water temperature in the bathroom #3 read 102.4 degrees Fahrenheit (front to back).
The conference room was observed with a couple of tables. The room is primarily used for storage of extra furniture and supplies. Located inside the room is a private bathroom equipped with a shower stall, toilet, sink and is currently not used.
A first aid kit containing band aids, tweezer, scissors and thermometer was observed and a first aid manual.
Evidence of Liability Insurance was reviewed. Limits of 1 million per occurrence and 3 million total annual aggregate were noted. However, the limits are shared by other locations on the same policy.
Two fire extinguishers were observed in facility. One is located in the lobby facing Hamlin Street and one at the end of the resident hallway. Both were last serviced on 10/9/23.
The hardwired smoke and carbon monoxide combination detectors located in the resident bedrooms, hallway and in the dining room were tested and were operational.
The facility has a sprinkler system and a copy of the last inspection report was requested
A resident in bedroom #6 uses oxygen and no "No Smoking, oxygen in use" signs were observed. The fire department needs to be notified of oxygen use at the home.
Hygiene products were observed in the bathrooms and extra are stored in the medication room
Night lights were observed in the resident rooms and in the hall way.
Observed in the center courtyard was a patio table with an umbrella and 8 chairs.
Trash cans in the back yard was observed to be in good condition and were tightly sealed.
Mops, brooms and buckets need to stored away.
The backyard and front yard need general cleaning.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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: DOLLY HOUSE	FACILITY NUMBER: 195850495
	VISIT DATE: 09/25/2024

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The following corrections need to be made prior to licensure:

Non-perishable foods for a minimum of 7 days need to be purchased
Full sized blankets need to be purchased for resident use
provide confirmation that the liability insurance meets Title 22 requirements
adjust the water heater to ensure that the water temperature is within Title 22 requirements of 105 to 120 degrees Fahrenheit
Ensure that the window screens are dust free
Provide non-skid mats in all 3 showers
provide a copy of the fire sprinkler system inspection report
place "No smoking, oxygen in use" in all appropriate locations
store away the mops, brooms and buckets
conduct general cleaning in the backyard and front yard.

Applicant will notify LPA Yee and provide evidence of corrections as soon as it has been completed.

Component III was conducted with Jennifer Pippard and Corrine Botte.

Exit interview was conducted.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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