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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602651
Report Date: 03/25/2024
Date Signed: 03/25/2024 01:24:06 PM

Document Has Been Signed on 03/25/2024 01:24 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.RO, 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:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Meg ItchonTIME COMPLETED:
01:45 PM
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On 03/25/24, 9:00AM Licensing Program Analysts (LPAs) Raymond Comer and Gina Saucedo conducted an unannounced Annual Required visit to this facility. LPA'S met with caregiver, Rodel Mayuga. Mr. Mayuga informed LPAs that the Administrator was currently not at the Facility and called designee co-Administrator, Meg Itchon, who showed up twenty minutes (20) later, and the purpose of visit was stated. The facility is licensed as a single-story residence, 4 Ambulatory, Age range 1 through 59, Developmentally Disabled. Facility has three (3) residents 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 bodies of water in the facility.

At 9:40AM, LPAs conducted a tour of the physical plant with the co-administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Side door is located west of the house, exiting to back yard. Screening area is located immediately upon entrance. Door signage displays, “Everyone entering facility must wear mask and must be screened.” Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Signage to wear a mask, and other Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, physical distancing and other necessary signage were posted in the bathroom and throughout the facility. All trash cans were observed to be with cover. The facility has submitted and approved Mitigation and Infection plan. Required postings are prominently displayed and observed to be current at the facility.

Fire Detection/Protection systems are present at facility. Multiple smoke alarms are installed, hardwired and interconnected. Carbon monoxide detector alarm is installed and tested. Fire extinguisher is located in Kitchen area; displayed as fully charged, with inspection service date/purchase date: 02/22/2024. Disaster drills were last conducted on 3/1/2024.

LIC 809C-continued
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TULSA HOME OF GRANADA HILLS
FACILITY NUMBER: 197602651
VISIT DATE: 03/25/2024
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Living room area maintains sufficient lighting. Furnishings, exercise equipment, games, and reading materials were checked for wear and tear and are found to be clean, and in good condition and available for residents.

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. The facility is observed to have sufficient food supply for the residents, both perishable and non-perishable.



Temperature of facility wall thermostat displayed setting of 69.0°F. Within the required range.

Bedrooms are observed as clean, properly furnished and maintain sufficient lighting. A Laundry area is located in the hallway. Laundry soaps and other cleaning agents are stored in a locked cabinet. Linen storage observed to have adequate supply of linen and towels.

Bathrooms were observed to be clean and sanitary with necessary supplies required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 110.9°F. Within the required range.



Garage is attached to the house and observed to be locked and inaccessible to residents. Garage is also used as storage for frozen foods, extra water and PPE supplies.

Resident 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 is accessible and stored in the living area desk cabinet.

Staff records were checked. Staff present has criminal record clearances and are associated to this facility.
Staff records appear to be complete and current.

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: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC809 (FAS) - (06/04)
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