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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604417
Report Date: 02/03/2022
Date Signed: 02/03/2022 11:17:42 AM

Document Has Been Signed on 02/03/2022 11:17 AM - 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:EL-SHADDAI'S HOME IIFACILITY NUMBER:
197604417
ADMINISTRATOR:COLLINS AKINSOLAFACILITY TYPE:
735
ADDRESS:18915 LANARK STREETTELEPHONE:
(818) 886-1364
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 4DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Collins AkinsolaTIME COMPLETED:
11:18 AM
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At approximately 9:55 AM on 02/03/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection using the Infection Control Domain of the Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff and later Administrator and disclosed the reason for the visit.

Census: 4

Entry: At the front door, LPA observed 4 signs related to COVID-19. The signs pertained to the facility’s visitation policy, masking requirement, and COVID prevention policies.

Screening: Upon entering the one, main entry point, LPA was screened by staff for COVID-19. Staff took LPA’s temperature, and LPA submitted contact tracing information in a visitor log. On the screening table, LPA observed 4 boxes of N95 masks, 2 boxes of surgical masks, and a digital thermometer. LPA recommended the facility record symptom and temperature information in the log too. Administrator created a new log for the symptom screening information during the inspection.

At approximately 10:11 AM, LPA conducted a physical plant tour.

Dining Room: LPA observed a fully charged fire extinguisher and a first aid kit near the kitchen. A medication cabinet with client medications was locked. Signs hung near the entrance and dining room pertaining to symptoms of COVID-19, cleaning practices, cough etiquette, droplet precautions, and handwashing reminders. LPA also observed postings for client personal rights, and activity schedule, house rules, grievance procedures, and a confidential complaint hotline.

Kitchen: LPA observed clean floors, walls, and ceilings in the kitchen and dining area. LPA recommended a handwashing instruction sign be placed near the kitchen sink.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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: EL-SHADDAI'S HOME II
FACILITY NUMBER: 197604417
VISIT DATE: 02/03/2022
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Garage: LPA observed an adequate supply of PPE in the garage along with operable laundry machines. Emergency exits were unlocked and free from obstruction. Hazardous materials were in a locked shed.

Common Areas: LPA observed clients utilizing common areas and watching television. Couches were arranged to provide social distancing, and all areas were clean. All furniture was in good repair.

Outside Space: LPA observed another locked shed and an unlocked exit gate which was free from obstruction. A grill stood outside without a propane tank. LPA observed clients walking in the backyard while staff supervised. There was a shaded patio area with seating as well.

Bedrooms: The facility contained 4 bedrooms. 3 bedrooms were private, 1 bedroom was shared. The shared bedroom was located near the backyard, and 3 individuals were tearing out carpet and installing tile. Bedding and furniture was outside on the patio. LPA continued down the hall and observed two private bedrooms which were clean with furniture in good repair. At the end of the hall, LPA inspected a staff bedroom. The staff bedroom contained a lighter which was supervised at the time. LPA observed a lock on the staff door, and staff informed LPA that the staff room is locked when it is not attended.

Bathrooms: The facility contained 2 bathrooms. One bathroom was inside the shared bedroom. That bathroom contained paper towels, a trash can, and liquid soap under the sink. The other bathroom was near the front entrance and contained paper towels, a trash can, a handwashing instruction sign, and liquid soap under the sink. Due to client lack of hazard awareness, Administrator noted soap and sanitizer are kept under sinks. LPA recommended additional handwashing instruction signs in the kitchen and the bathroom in the shared bedroom.

Other areas: LPA observed a closet in the hallway with an adequate supply of clean linens. LPA observed a locked closet near the entrance with facility files.

At approximately 10:30 AM, LPA and Administrator reviewed the facility’s mitigation practices. The facility has an approved Mitigation Plan on file.

Exit interview conducted and report issued.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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