197603417-9-2-2023-31-AS-JGTN-CVAUKG-20230902153907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603417
Report Date: 09/02/2023
Date Signed: 09/02/2023 03:40:25 PM

Document Has Been Signed on 09/02/2023 03:40 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:	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: 6	DATE:	09/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Rosanna Tomaneng - Administrator		TIME COMPLETED:	03:45 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	A One (1) Required Annual visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Rosanna Tomaneng and purpose of visit was stated. This is North Los Angeles Regional Center vendored facility level 2. At 12:30 PM, A tour of the physical plant was assessed 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 at the backyard. The facility has sufficient stock of PPE in the storage room. Facility has four (4) client bedrooms: two (2) are shared and two (2) are private. The facility has two (2) bathrooms. There is one additional bedroom 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 ample supply of clean linen and towels. Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 117.6°F and within the required range. 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. (continued to LIC 9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2023

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSANNA ADULT RESIDENTIAL HOME	FACILITY NUMBER: 197603417
	VISIT DATE: 09/02/2023

NARRATIVE

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(continued from LIC 809)

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 below the kitchen sink.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is set at 74°F and observed to be within the required range.
Fire extinguisher. There are two (2) fire extinguisher in the facility: one (1) in the kitchen and another one (1) in the hallway near the bedrooms. Extinguishers were observed to be operable and last checked on 05/05/23. Smoke alarms are interconnected, tested and observed to be operable.

There is no garage at the facility, only car port at the front. The former garage is now an additional dwelling unit (ADU) with a separate address and separate ingress and egress.

Client records were reviewed for current IPP and/or Needs and Service 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 located near the kitchen. Medication records and procedures reviewed with staff. 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 07/03/23. Required posting are observed to be complete and current and displayed properly at the facility.

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: 09/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2023

LIC809 (FAS) - (06/04)

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