197600256-5-13-2023-31-AS-MCAA-CRSPZ7-20230513114505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197600256
Report Date: 05/13/2023
Date Signed: 05/13/2023 11:45:15 AM

Document Has Been Signed on 05/13/2023 11:45 AM - 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EUNICE HOME		FACILITY NUMBER:	197600256
ADMINISTRATOR:	AGBEDE, SONNY		FACILITY TYPE:	735
ADDRESS:	11611 BALBOA BLVD.		TELEPHONE:	(818) 368-9242
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6		CENSUS: 6	DATE:	05/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Cherish Abati, Araba Adeniyi		TIME COMPLETED:	11:45 AM

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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Cherish Abati and Araba Adeniyi. They were explained of the reason for the visit. At approximately 9:00am, with the assistance of staff, LPA took a tour of the physical plant. The smoke alarms are hardwired and interconnected. The carbon monoxide detector functions properly. The fire extinguisher is located in staff quarters. The charge date is 03/28/2022. Earthquake drill was last conducted in December 21, 2022. Fire and Emergency drill was last conducted on February 28, 2023. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored and inaccessible to residents in care. LPA did not observe any cleaning supplies and toxins present in the kitchen area. Bedrooms: There are four (4) bedrooms designated for residents' use. Two were for private use and two are shared. Each bedrooms were observed to be properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two and a half (2 1/2) bathrooms designated for residents' use. Each bathroom were properly supplied and had functional fixtures. Hot water temperature was measured at 115 degrees Fahrenheit. No cleaning supplies were observed in the bathroom. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2023

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EUNICE HOME	FACILITY NUMBER: 197600256
	VISIT DATE: 05/13/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area is located outside. No detergents or toxins were observed accessible in the laundry area. The backyard had additional storage space. LPA inspected the inside and did not observe anything present which could pose a health and safety hazard to the clients in care. There is a staff work station located adjacent to the kitchen where medications are stored and maintained. Medications and medication records were observed locked and inaccessible to clients in care. Client and staff records were also maintained in the staff work station.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2023

LIC809 (FAS) - (06/04)

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