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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600845
Report Date: 06/13/2024
Date Signed: 06/13/2024 12:41:37 PM

Document Has Been Signed on 06/13/2024 12:41 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:APPLE STREET, LARC HOMEFACILITY NUMBER:
197600845
ADMINISTRATOR/
DIRECTOR:
ROSE MARIE SALGADOFACILITY TYPE:
735
ADDRESS:24624 APPLE STREETTELEPHONE:
(661) 259-2009
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 6CENSUS: 0DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Bertha ChavarinTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual inspection. LPA was greeted by staff Bertha Chavarin, who allowed LPA to enter and who was informed the reason of the visit. Administrator Donna Rodriguez was contacted, and was also informed the reason of the visit.

A physical plant of the inside and outside was conducted with staff. LPA observed that the facility has (4) bedrooms, with (1) room used for staff office, and (3) rooms for clients. The current census is (3) and during the visit, all clients were at program. There are (2) bathrooms; which included grab bars, non-skid mats, and soap and towels. Hot water temperature measured at 105.8 degrees°F

The front main door is the only entrance being utilized at the facility. There is a sign on the front door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. All staff and clients are vaccinated.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors and the walls inside the facility. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be covered.

Bedrooms were toured and observed to be clean and appropriately furnished. LPA observed a bed, chair and dresser. Linens were clean and in good repair.

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean. Living/dining/family room was checked for functionality (wear and tear). Furniture was observed to be in good condition.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: APPLE STREET, LARC HOME
FACILITY NUMBER: 197600845
VISIT DATE: 06/13/2024
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Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions and other toxins were observed to be locked in the cabinet below the sink; including the garage area. Food. The facility is observed to have sufficient food supply for clients. There are an extra fridge and freezer stocked with food in the garage area.

Fire extinguisher was fully charged. Fire alarms are hardwired and tested and observed to be operational. There were carbon monoxide detectors installed in the facility. The facility is equipped with sprinkler system.

Medication were observed to be locked, inaccessible and stored in the cabinet inside the staff room. There was a complete first aid kit located in the supply room inside the staff room closet. Knives and sharps are locked and secured in a kitchen drawer.

Garage is attached to the house and observed to be locked. Laundry room is located inside the garage.

Backyard has shaded area and outdoor furniture for clients. There is also a locked shed being used as storage for old equipment.

Client records. Clients record appeared to be complete and current. P& I money and records accurate.

Staff records were also reviewed. All staff present records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty.

There are no health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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