197601489-10-20-2023-29-AS-EPEI-CWSSVS-20231020141313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197601489
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:13:32 PM

Document Has Been Signed on 10/20/2023 02:13 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CARRIE'S BOARD AND CARE		FACILITY NUMBER:	197601489
ADMINISTRATOR:	CARRIE ACOSTA		FACILITY TYPE:	740
ADDRESS:	8430 COLBATH AVENUE		TELEPHONE:	(818) 893-7619
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 3	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Roberto Gamilla		TIME COMPLETED:	02:30 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 1:00 p.m., the LPA met with staff and explained the reason for the visit. At 1:20 p.m., the Licensee arrived at the facility, but shortly left. At 1:13 p.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:14 p.m., hot water measured at 106.1-degree Fahrenheit. Medications are located in a locked filing cabinet near the kitchen area. First aid kits are located inside a kitchen cabinet. Cleaning solutions items were inaccessible and locked away inside a kitchen cabinet. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms, three (3) for resident's use and one (1) for staff. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: The facility has two (2) bathrooms, one (1) for resident use and one (1) for staff use. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 1:18 p.m., hot water measured at 110.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. OUTDOOR SPACE: At 1:19 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. There is one (1) locked shed in the back patio that is used for storage. Laundry units are located inside the garage. The garage is attached to the house but remains inaccessible to residents. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIE'S BOARD AND CARE	FACILITY NUMBER: 197601489
	VISIT DATE: 10/20/2023

NARRATIVE

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COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 10/29/2022. At 1:25 p.m., fire alarms/ carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallway.

Due to time constraints the LPA will return to complete the annual at a later date.

No deficiencies were observed at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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