197604906-10-5-2022-31-AS-NRED-CJWN4P-20221005100817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604906
Report Date: 10/05/2022
Date Signed: 10/05/2022 10:08:29 AM

Document Has Been Signed on 10/05/2022 10:08 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:	DORIS' RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	197604906
ADMINISTRATOR:	DORIS DUONG		FACILITY TYPE:	735
ADDRESS:	8012 NEWCASTLE AVENUE		TELEPHONE:	(818) 774-9706
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 4		CENSUS: 3	DATE:	10/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Marilyn Balancio		TIME COMPLETED:	10:20 AM

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At 9:05 a.m. on 10/05/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

The facility was last visited on 08/10/2022 for a complaint visit. It is a single story building with 4 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 4 ambulatory residents.

LPA observed a maintained front yard. Signs for the facility’s visitation and masking policies were hung on the front door. Other postings inside included administrator certificate, facility license, confidential complaint contacts, Emergency Disaster Plan, personal rights, monkeypox precautions, COVID precautions, neighborhood complaint procedure, and activity schedule. LPA was screened for infectious disease upon entry. The screening station contained a visitor log, digital thermometer, surgical masks, N95 masks, gloves, hand sanitizer, and sanitizing wipes. The visitor log tracked temperature, symptoms, and vaccination status.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 9:31 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit. The hallway contained 2 linen closets with adequate supplies of fresh linens. LPA observed a sufficient supply of perishable and non-perishable foods in the kitchen. Appliances were sanitary and functional. Sharps were locked above the countertop. A laundry area was located by the kitchen. LPA observed a washer and a dryer in working condition. Detergents and cleaning solutions were locked above the washer.

The facility had 4 bedrooms. All bedrooms were private, and one bedroom was designated for staff. The staff bedroom was locked and free of hazards. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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: DORIS' RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197604906
	VISIT DATE: 10/05/2022

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The facility had 2 bathrooms. All bathrooms contained liquid soap, a handwashing instruction sign, a trash can with a tight fitting lid, and a non-skid mat in the shower. At 9:37 a.m. LPA measured the water temperature in the shared bathroom to be 110.3 degrees Fahrenheit.

A covered patio area contained furniture in good repair. The back yard had a gardening area with fruit trees. An additional refrigerator and freezer were outside along with two locked sheds. The garage was locked and inaccessible. Exit doors were unlocked. All emergency exit paths were free from obstructions. Exit gates were unlocked. At 9:34 a.m. LPA observed a fully charged fire extinguisher in the hallway, It was purchased on 10/19/2021. At 9:37 a.m. LPA tested the smoke detector and carbon monoxide detectors to be operational.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC809 (FAS) - (06/04)

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