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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602651
Report Date: 08/13/2023
Date Signed: 08/13/2023 12:09:05 PM

Document Has Been Signed on 08/13/2023 12:09 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:TULSA HOME OF GRANADA HILLSFACILITY NUMBER:
197602651
ADMINISTRATOR:MICHAEL LEWANDOWSKIFACILITY TYPE:
735
ADDRESS:16430 TULSA STREETTELEPHONE:
(818) 360-3141
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
08/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Rosalie Lewandowski - AdministratorTIME COMPLETED:
12:00 PM
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A One (1) year Required visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Rosalie Lewandowski and purpose of visit was stated. This facility is North Los Angeles Regional vendored facility Level II.

At 8:49 AM, A tour of the physical plant was conducted with Ms. Lewandoswki and the following was noted:

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

The facility had submitted and approved Mitigation and Infection plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted on the walls. 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 with cover. The facility has a designated visitors' area inside which is enclosed. The facility has sufficient stock of PPE in the storage room.

Facility has three (3) client bedrooms, two (2) private rooms and one (1) shared room, facility has two (2) bathrooms. An additional bedroom is designated for staff use. There is no body water in the facility.
Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have sufficient supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 115.1°F and within the required range.

(continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TULSA HOME OF GRANADA HILLS
FACILITY NUMBER: 197602651
VISIT DATE: 08/13/2023
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet on the main entrance hallway. Knives and sharps were also stored in a locked cabinet and inaccessible to residents.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguisher. The fire extinguisher is located in the kitchen and observed to be operable and last serviced on 01/23/23. Smoke alarms are hardwired and interconnected. Alarms were tested and observed to be operable. There was a carbon monoxide detector alarm installed in the facility. Garage is attached to the house and was observed to be locked and inaccessible to residents. Garage is also used as storage for frozen foods and old equipment. Laundry area is located in the bedroom hallway. Laundry soaps and other cleaning agents are stored in a locked cabinet.

Client records were reviewed for current IPP and/or Needs and Services plans, physician report, admission agreements and P & I funds. Client records appeared to be complete and current.


Medication was observed to be inaccessible and stored in a secured cabinet. There is a complete First Aid kit in the medication cabinet.
Staff records were checked. Staff present has criminal record clearances and associated to this facility.
Staff records appear to be complete and current.

Disaster drill was last conducted on 05/29/23. Required posting are observed to be complete and current and displayed properly at the facility.

There was no immediate 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: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2023
LIC809 (FAS) - (06/04)
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