197604295-8-12-2023-31-AS-MCAA-CUMSF3-20230812134939

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604295
Report Date: 08/12/2023
Date Signed: 08/12/2023 01:50:07 PM

Document Has Been Signed on 08/12/2023 01:50 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:	MCLENNAN GUEST HOME		FACILITY NUMBER:	197604295
ADMINISTRATOR:	MARILYN SHIRAZI		FACILITY TYPE:	735
ADDRESS:	12139 MCLENNAN ST.		TELEPHONE:	(818) 832-5523
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 4		CENSUS: 4	DATE:	08/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Clyde Acabal, Andres Jacinto, Marites Jacinto		TIME COMPLETED:	02:00 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	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the assistant administrator, Clyde Acabal, and staff, Clyde and Marites Jacinto, and explained the reason for the visit. At 9:20am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected. Carbon monoxide detector is located by the kitchen. The facility has two fire extinguishers. One is located in the kitchen, and the other in the laundry room. The charge date is 03/21/2023. The facility last conducted their fire and earthquake drills on June 26, 2023. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of properly stored perishable and non-perishable food at the facility. There is also an extra supply of perishable and non-perishable food in the garage. Knives are kept inaccessible from clients in a locked drawer. Bedrooms: There were three (3) bedrooms designated for residents' use. Two (2) rooms are private and one (1) is shared. The resident bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. The facility also has two rooms designated for staff use. Bathrooms: There are three (3) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 110 degrees Fahrenheit. No cleaning supplies observed in resident bathrooms as they were stored in the locked laundry room. Common Areas: These included the living room and dining area. The common areas were properly furnished. Furniture in both the living room and dining area were clean and in good repair. Floors were also clean and presented no tripping hazard. Entry/exits were clear of obstruction. There is a fire place which

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023

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

FACILITY NAME: MCLENNAN GUEST HOME	FACILITY NUMBER: 197604295
	VISIT DATE: 08/12/2023

NARRATIVE

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is properly screened. No fire-place tools were observed during the day of the inspection.

Surrounding Grounds: Driveway and entrance area was clear of obstruction. The backyard had outdoor furniture and exercise equipment appropriate for outdoor use. There is a storage in the backyard, which was observed locked. The lawn in the backyard had big enough space to conduct outdoor activities and exercise. The side gate of the home was checked to insure it was free and clear of locks or any hindrance from exiting. The laundry area and detergents are located by the garage. It is kept locked and inaccessible to the residents. The garage is used as storage for PPE supplies and additional non-perishable food items. There was also two refrigerators used for storage for additional perishable food items.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were kept in a locked cart located in the dining room. LPA reviewed medications and the MAR for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a copy of this report issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023

LIC809 (FAS) - (06/04)

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