197601032-12-16-2023-31-AS-MCAA-CYKT5C-20231216132520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197601032
Report Date: 12/16/2023
Date Signed: 12/16/2023 01:26:03 PM

Document Has Been Signed on 12/16/2023 01:26 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EUNICE HOME II		FACILITY NUMBER:	197601032
ADMINISTRATOR:	AGBEDE, SONNY		FACILITY TYPE:	735
ADDRESS:	17131 COURBET STREET		TELEPHONE:	(818) 831-5282
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6		CENSUS: 6	DATE:	12/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Iyinoluwa Onanga		TIME COMPLETED:	01:30 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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Iyinoluwa Onanga, and explained the reason for the visit. At 9:12am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke and carbon monoxide alarms are tested and observed to be operable during the visit. The fire extinguisher is located in staff work station, located by the kitchen. Fire extinguisher was last charged 05/15/23. 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 and cleaning supplies were stored inaccessible from the residents. Bedrooms: There are five (5) bedrooms. Four (4) bedrooms designated for residents' use. Two (2) rooms are private, and two (2) are shared. The fifth (5th) bedroom is designated for staff. The four (4) bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are four (4) bathrooms. Three (3) of the bathrooms were designated for residents' use, and one (1) is designated for staff. Bathroom in use for the residents were properly supplied and had functional fixtures. Hot water temperature was measured at 108.4 degrees Fahrenheit. Common Areas: These included the living room, family room and dining area. The common areas were properly furnished, which included couch, chairs, tables and a television. The dining room table was large enough to seat six (6) residents. Furniture was in good repair. Floors were mopped and cleaned. No hazard present.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

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 3

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 II	FACILITY NUMBER: 197601032
	VISIT DATE: 12/16/2023

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
26
27
28
29
30
31
32

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The swimming pool was in between a fence, that was at least five feet high, and a wall at the opposite end. The gate, to enter the pool area was observed to be locked. The fence was surrounding the pool to the wall to prevent access to the pool. The outdoor area was free of hazards.

Garage: The garage is used for storage and laundry area. Cabinets where cleaning supplies and detergents are being kept was observed locked. The laundry area and detergents are located by the kitchen.
Staff Work Station: Staff work station is located near the dining room and kitchen area. Resident and staff records maintained here. Medications were observed locked in a cabinet.

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 compliance.

Medications: Medication and Medication Records were observed and reviewed for storage and proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D). 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: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/16/2023 01:26 PM - It Cannot Be Edited

Created By: Michael Cava On 12/16/2023 at 12:31 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EUNICE HOME II	FACILITY NUMBER: 197601032
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: During the anual visit, LPA observed disinfectant, accessible in resident bathroom.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one bathroom storage, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/16/2023
	Plan of Correction
1 2 3 4	Staff removed the disinfectant spray immediately during the visit. No further correction required.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Eva Miller

LICENSING EVALUATOR NAME:

Michael Cava

LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3