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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603453
Report Date: 12/12/2024
Date Signed: 12/12/2024 06:17:54 PM

Document Has Been Signed on 12/12/2024 06:17 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:SHALIS CARE CENTERFACILITY NUMBER:
197603453
ADMINISTRATOR/
DIRECTOR:		PEGGY PAYNE WALTERSFACILITY TYPE:
735
ADDRESS:925 ALTA PINE DRIVETELEPHONE:
(626) 798-1076
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:34 PM
MET WITH:Alice Walters - Regional AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with Regional Administrator Alice Walters. Purpose of the visit is stated. This is a San Gabriel/Pomona Regional Center vendored facility Level IV-G.

LPA conducted physical plant tour inside and out at 2:55 PM. During the tour, LPA observed that the facility has four (4) bedrooms and three (3) bathrooms. There is no body of water in the facility.

The front main door is the only entrance being utilized at the facility. Screening area is located immediately before entrance. Sign in sheet, hand sanitizer, gloves and masks are available. This facility is fire cleared for four (4) ambulatory.

The facility had submitted and approved Mitigation and Infection Plan.

Signs of Covid 19 prevention protocol signs were posted indoors. 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.

Bedrooms were toured and observed to be clean and appropriately furnished.
Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 105.1°F to 112.8°F

(continued to LIC 809-C)
Troy AgardTELEPHONE: (818) 596-4342
Jose Gary TanTELEPHONE: (323) 213-1149
DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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: SHALIS CARE CENTER
FACILITY NUMBER: 197603453
VISIT DATE: 12/12/2024
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean 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 is observed to be clean and sanitary. All disinfectants, cleaning solutions and other toxins were observed to be locked in the cabinet located in the TV room. Laundry room is located adjacent to the TV Room. Laundry detergent and other toxins are also locked cabinet in the TV room.
Food. The facility is observed to have sufficient food supply both perishable and non-perishable for clients. Temperature of facility wall thermostat was set at 73.0°F and observed to be within the required range.
Fire extinguisher was observed to be located in the bedroom hallway. Fire extinguisher was observed to be operable and last inspected on 04/16/24. Fire alarms are hardwired, tested and observed to be operational. There was a carbon monoxide detector installed in the facility.
Medication were observed to be locked, inaccessible and stored in the cabinet in the TV room. There was a complete first aid kit located inside the medication cabinet. Knives are locked in the medication cabinet in a separate drawer in a locked tool box.
Garage is detached to the house and observed to be locked and inaccessible to clients. Garage was being used as a storage for old equipment.
Client records. All four (4) client records were reviewed. Clients record are complete and current.
Staff records were also reviewed. All staff present records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 11/12/24. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no health and safety hazard observed during the day of inspection.

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

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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