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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604537
Report Date: 11/06/2023
Date Signed: 11/06/2023 09:54:06 PM

Document Has Been Signed on 11/06/2023 09:54 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOTHIC HOMEFACILITY NUMBER:
197604537
ADMINISTRATOR:ROSALIE M. LEWANDOWSKIFACILITY TYPE:
735
ADDRESS:9919 GOTHIC AVENUETELEPHONE:
(818) 894-4353
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria CalaudTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Gina Saucedo arrived at 9:45am and met with Maria Victoria Calaud for an annual visit. The licensee Rosalie Lewandowski was contacted and appeared at 10:15am then administrator Margaret Itchon was contacted as well and appeared for the visit at 11:12am.

At approximately 10:10 am team conducted a tour of the facility with the caregiver Maria Victoria Calaud and the following was observed:

Common Areas: Team toured all common areas of the facility. LPAs observed common areas to be very clean and tidy. LPAs observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair.

The facility maintains a comfortable temperature at 70 degrees Fahrenheit. LPAs observed fire extinguishers throughout the facility to be full and serviced 1.23.2023. The smoke/carbon monoxide detectors are operational. There are no issues with Fire Clearance.

Infection control: LPAs reviewed facility mitigation plan to make sure licensee was following current infection control recommendations. LPAs obtained a copy and reviewed the infection control plan during this visit.

Food Inspection: LPAs conducted a food inspection tour. LPAs observed there to be sufficient stock of two-day perishable and one week of non-perishable foods. The menu was posted for review (ARF), snacks and beverages are available for the resident in the facility when they want. Frozen foods are properly wrapped and stored appropriately and dated. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides, and toxic cleaning supplies were stored and locked away. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOTHIC HOME
FACILITY NUMBER: 197604537
VISIT DATE: 11/06/2023
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Resident room: LPAs toured all 4 resident rooms. LPAs observed rooms to have appropriate bedding sheets, pillowcase, and blankets which are in good condition. There is at least one chair, night stand and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition.

Bathrooms: LPAs toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 118.9F and 117.5F. LPAs observed appropriate grab bars each bathroom. Towels and washcloths are not shared. Residents have sufficient amount of supplies for personal hygiene which is provided by the licensee.

Outside areas: LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water which is unsecured. The garage is attached to the home and is kept locked inaccessible to clients.

Laundry service: There is enough linen available to change weekly or more if need.

Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: LPAs reviewed clients files for current IPP’s and surety bonds (LIC 402) a copy was handed to LPAs. Planned activities are offered. Team reviewed one out of four resident funds and observed receipts and funds balanced.

Personnel records were checked for expired or missing certificates and clearances: LPAs conducted a file review of staff for criminal record clearances and current first aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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