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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600960
Report Date: 07/08/2023
Date Signed: 07/08/2023 04:18:34 PM

Document Has Been Signed on 07/08/2023 04:18 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
Lookup Error,
, CA
FACILITY NAME:AIZABEL HOMEFACILITY NUMBER:
197600960
ADMINISTRATOR:TOLENTINO, MARIA LILIANFACILITY TYPE:
735
ADDRESS:1425 ETHEL ST.TELEPHONE:
(818) 545-3975
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY: 6CENSUS: 4DATE:
07/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Muara PanganibanTIME COMPLETED:
02:27 PM
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On 07/08/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Muara Panganiban. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory adults ages 18-59. The clients are all Laterman Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) client's rooms, (3) bathrooms, a living area, a dining area, a kitchen, office, an outside seating area, and an outdoor storage area.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 107.9 degrees F. A comfortable temperature of 74 F. degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were fully charged. A review of the Medication Records Administration (MAR) was observed to be complete.

(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2023
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
Lookup Error,
, CA
FACILITY NAME: AIZABEL HOME
FACILITY NUMBER: 197600960
VISIT DATE: 07/08/2023
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 05/29/23 and earthquake drill conducted on 05/30/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 11/01/22-11/01/23 and a current Surety Bond coverage.

An audit of client #1-#4 (C1-C4) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. An audit of the resident's P&I is maintained in order and complete. Interviews were conducted with (4) clients and (2) staff. The facility has the current administrator's certification on file for Muara Panganiban expiration date 08/19/2023 #60003274735.

No deficiencies during this inspection visit.

An exit interview was conducted with Muara Panganiban and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2023
LIC809 (FAS) - (06/04)
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