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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604295
Report Date: 05/17/2024
Date Signed: 05/17/2024 12:19:16 PM

Document Has Been Signed on 05/17/2024 12:19 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 HOMEFACILITY NUMBER:
197604295
ADMINISTRATOR/
DIRECTOR:		MARILYN SHIRAZIFACILITY TYPE:
735
ADDRESS:12139 MCLENNAN ST.TELEPHONE:
(818) 832-5523
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Claro "Roy" SalomonTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff Roy Salomon and explained the reason for the visit.

At approximately 9:15am, with the assistance of staff, LPA took a tour of the physical plant. The facility is a level 4G Adult Residential Facility. The building is one story. Required postings were observed in the entry area. The smoke alarms are interconnected. There are two carbon monoxide detectors. One in the kitchen and one in the hallway by resident rooms. The facility has two fire extinguishers. One is located in the kitchen, and the other in the laundry room. The charge date is 03/14/2024. The facility last conducted their fire and earthquake drills on May 8, 2024.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of properly stored perishable and non-perishable food at the facility. Knives are in a locked drawer. Cleaning supplies are kept locked underneath the sink.

Bedrooms: There are five (5) total bedrooms. Two bedrooms are designated for staff. Three (3) bedrooms are designated for residents' use. Two (2) rooms are private and one (1) is shared. The bedrooms designated for resident use were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are three (3) bathrooms. Two (2) are are full with shower, toilet and sink. One (1) bathroom just has the toilet and sink. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 119 degrees Fahrenheit. No cleaning supplies observed.

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. The dining room table was large enough to seat six (6). Floors were clean and also in good repair. There is a fire place which
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MCLENNAN GUEST HOME
FACILITY NUMBER: 197604295
VISIT DATE: 05/17/2024
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is properly screened. No fire-place tools were observed during the day of the inspection.

Surrounding Grounds: Entry and exits to the front and back yard were 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 backyard has big enough space to conduct outdoor activities. The side gate of the home was checked to insure no locks installed and exit is clear.

Laundry: The laundry room and detergents are located in between rooms #3 and #4. Detergents and cleaning supplies were stored there. Door to enter the laundry area is kept locked at all times.

Garage: The garage is located adjacent the laundry room. There is no resident access. The garage is used for extra storage of non-perishable food, emergency water and for PPE supplies. In addition, there are two refrigerators in the garage for storage of additional perishable food items.

Staff Workstation/Office: There is a small staff work station, located at the corner of the kitchen where one of the fire extinguishers is kept.

Resident Files: Resident files are kept in one of the staff rooms that is locked. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff records also kept in the staff room that is locked. LPA conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: The medication cart is located in the dining room Medication and Medication Records were kept in the locked cart. LPA reviewed medications for proper storage and 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: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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