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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600306
Report Date: 03/09/2022
Date Signed: 03/10/2022 08:07:18 AM

Document Has Been Signed on 03/10/2022 08:07 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ACTIVITIES FOR RETARDED CHILDREN AND ADULTSFACILITY NUMBER:
197600306
ADMINISTRATOR:CAROLE-ANN SCOTTFACILITY TYPE:
775
ADDRESS:6456 WHITSETT AVE.TELEPHONE:
(818) 762-4365
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 36CENSUS: 19DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jennifer PippardTIME COMPLETED:
03:01 PM
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On 03/02/2022 at 1:00 p.m., Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices and procedures. LPA Urena met with Day Program Coordinator (DPC) Andrea Marroquin, and explained the reason for the visit. The DPC contacted the Executive Director (ED) Jennifer Pippard over the phone, and she arrived at the facility at 1:15 p.m.

Infection Control: Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient.

At 1:30 p.m., LPA Urena, and the DPC conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards, and to ensure the facility is in compliance with Title 22 Regulations.

Common Areas: 1:40 p.m. LPA Urena observed the walls, ceiling, and flooring to be clean and in good condition. At the time of the visit, the common seating area, and dining room furniture was observed to be in good condition. Fire extinguisher was observed to be serviced within the last year. The facility has several rooms which are utilized for activities with the clients in the day program. The rooms are stocked with a variety of craft materials, music instruments, computers and other activity materials. The second floor has three administrative offices, one computer room and two bathrooms.

Continues on LIC809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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 2
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: ACTIVITIES FOR RETARDED CHILDREN AND ADULTS
FACILITY NUMBER: 197600306
VISIT DATE: 03/09/2022
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Kitchen: At 2:00 p.m. LPA Urena observed the kitchen area. This is a day program facility, and does not provide meals for clients. Clients bring their own lunch, which are stored in two refrigerators located in a room adjacent to the main dwelling.

Bathrooms: 2:15 p.m. LPA Urena observed the restrooms, which were clean, and stocked with sufficient amounts of soap and paper products in each restroom. Handwashing signs were displayed in each bathroom.

Outdoor Space: 2:30 p.m., LPA Urena observed the front yard to have round tables with chairs, and shade for clients to have meals. The backyard has a small shaded area. A basketball court and games area were found to be in good condition. The pool was fenced and locked during the visit.



No deficiencies were cited during this visit. Exit interview was conducted. The report was reviewed with licensee representative ED Jennifer Pippard, signatures were obtained, and a copy of the report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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