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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601032
Report Date: 09/15/2021
Date Signed: 09/15/2021 11:54:14 AM

Document Has Been Signed on 09/15/2021 11:54 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 IIFACILITY NUMBER:
197601032
ADMINISTRATOR:AGBEDE, SONNYFACILITY TYPE:
735
ADDRESS:17131 COURBET STREETTELEPHONE:
(818) 831-5282
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 5DATE:
09/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sonny Agebede/ LicenseeTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to complaint control number 31-AS-20210910153907. While touring the home at 10:00 am, LPA observed that the side gate is broken and does not close with a self latching mechanism. The facility is using a shoelace to keep the gate closed, but when LPA inspected the gate, it was open.

LPA continued the tour of the inside of the home. While touring room 2, with staff, LPA and staff member observed that a large couch was placed in front of the emergency exit, which prevented residents from using the door in case of emergency.

The Licensee arrived at the home at about 11:00 AM, and was made aware of the findings. The Licensee moved the couch out of the way of the door during the visit.

Exit interview conducted, deficiencies cited, and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2021
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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Document Has Been Signed on 09/15/2021 11:54 AM - It Cannot Be Edited


Created By: Patrick Shanahan On 09/15/2021 at 11:17 AM
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: 09/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2021
Section Cited
CCR
87307(d)(6)

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87307(d)(6) Personal Accommodations and Services. (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
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The licensee moved the couch during the visit. Cleared during visit.
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Based on observation, licensee did not ensure exit ways were clear from obstruction by placing a couch infront of the exit in room 2, which poses an immediate health and safety risk to residents in care.
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Type B
09/22/2021
Section Cited
CCR80087

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidence by:
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The Administrator agrees to fix the side gate and submit pictures or an invoice that the corrections has been made to the LPA by the POC date.
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Based on LPA and staff observation, the licensee did not ensure the side gate is able to close or to latch, which poses a potential risk to residents in care
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021


LIC809 (FAS) - (06/04)
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