197603417-8-11-2022-31-AS-TSMH-CH7UYP-20220811160013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603417
Report Date: 08/11/2022
Date Signed: 08/11/2022 04:00:30 PM

Document Has Been Signed on 08/11/2022 04:00 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:	ROSANNA ADULT RESIDENTIAL HOME		FACILITY NUMBER:	197603417
ADMINISTRATOR:	ROSANNA J. TOMANENG		FACILITY TYPE:	735
ADDRESS:	14605 HIAWATHA STREET		TELEPHONE:	(818) 897-6964
CITY:	MISSION HILLS	STATE: CA	ZIP CODE:	91345
CAPACITY: 6		CENSUS: 3	DATE:	08/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Maria Paz Smith		TIME COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced Annual Required visit to this facility at 12:55 pm. LPA Smiths’ temperature taken upon entry by staff Maria Paz Smith and Covid symptoms questions on sign in log. LPA informed staff the purpose of this visit. The administrator was called at 1:10 pm and authorized Maria Paz Smith to sign report.

LPA conducted a tour at 1:55 PM of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA was escorted to the living room and den area and observed adequate seating for cliens. Staff confirmed there are three (3) clients in the home. The living room and den area had furnishings, sufficient lighting and the area was clean.

Smoke alarms and carbon monoxide detectors were present and function properly. There are two (2) fire extinguishers. One is located near front entrance and the other is in kitchen both observed to be charged

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the three (3) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk and eggs observed with juice. The freezer is stocked with meats. Canned food and water stored in hall closet to the left of the front door.

Medications are locked in wall cabinet in hallway across from the kitchen. Medications observed to be locked and inaccessible to clients. The first aid kit is stored in locked staff room. LPA observed fully stocked Curad first aid kit with backup first aid supplies in a clear tote.

Sharps observed to be locked in drawer to the left of kitchen sink and inaccessible to clients. All the toxins, cleaning solutions and disinfectants are locked under kitchen sink and locked in closet to the
(Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSANNA ADULT RESIDENTIAL HOME	FACILITY NUMBER: 197603417
	VISIT DATE: 08/11/2022

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(Cont from 809)

left of front door. Laundry area located in kitchen across from staff room. Appliances observed to be in good repair.
There are four (4) bedrooms. A tour of the client’s bedrooms, bathrooms, personal accommodations, and common areas (all client bedrooms toured had the required furniture for clients’ comfort and safety). Common areas were observed for the ability to safely serve the needs of clients , including cleanliness, skid materials and grab bars. LPA observed a sufficient supply of linens in closet to the left of front door.

There two (2) bathrooms. Each bathroom has posted “wash your hands” sign and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 109, and 112.7-degrees Fahrenheit. The A/C dial is pending repair and administrator revealed the contracted technician has a repair window today: 08/11/22 between 3pm- 5p.m and arrived while LPA in facility.

LPA Smith advised staff to provide status of A/C repair when completed. Clients’ bedrooms and common areas currently being cooled by circular fans and ceiling fans.

There is a large patio table and chairs shaded by a large gazebo for clients use in the backyard. Patio furniture observed to be in good repair with adequate seating for the residents. There is a locked shed in the backyard observed to be storing PPEs, boxes and yard supplies. LPA requested a copy of infection control plan which will be sent by email.

There was no immediate health and safety hazard observed during the day of inspection. There are no deficiencies to report.

Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

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