197604906-12-20-2023-31-AS-HRAI-CYPPZ5-20231220104500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604906
Report Date: 12/18/2023
Date Signed: 12/20/2023 10:45:13 AM

Document Has Been Signed on 12/20/2023 10:45 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
WOODLAND HILLS S.RO, 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: 4	DATE:	12/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Marilyn Balancio		TIME COMPLETED:	04:45 PM

NARRATIVE

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At 12:30 p.m. on 12/18/2023, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with staff and later Administrator designee, Carolina Mateo, and disclosed the reason for the visit. LPA and staff toured the facility inside and out. 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.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 12:45 p.m. LPA measured the room temperature to be 70 degrees Fahrenheit. The hallway contained 2 linen closets with adequate supplies of fresh linens.

Kitchen: At 12:55 pm, LPA and Administrator designee toured the kitchen and LPA observed an adequate supply of perishable and non-perishable food. The vent above the stove was clean. Surfaces were sanitary. The house phone was located in the kitchen as well. Consumer medications were locked in the kitchen cabinet. LPA observed a sufficient supply of perishable and non-perishable foods in the kitchen. Appliances were sanitary and functional. Sharps were locked above the counter-top. 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.

Bedrooms: LPA observed the structure of the facility to be altered. According to the caregiver and Administrator designee, who confirmed to the LPA the facility had been changed and an additional room and was added to the facility for live-in staff in the covered patio area of the facility. The staff bedroom was locked and free of hazards. There are additional four (4) bedrooms designated for clients use and are part of the original sketch of the facility. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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: DORIS' RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197604906
	VISIT DATE: 12/18/2023

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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 1:08 p.m. LPA measured the water temperature in the shared bathroom to be 115.3 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 1:10 p.m.,LPA observed a fully charged fire extinguisher in the hallway and last serviced on 07/30/2023. At 1:20 p.m., LPA tested the smoke detector and carbon monoxide detectors to be operational.

During today's inspection, deficiency was cited on LIC 809D

Exit interview conducted. Appeal rights explained and copy of this report signed and issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2023 10:45 AM - It Cannot Be Edited

Created By: Huma Rahimi On 12/18/2023 at 04:00 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DORIS' RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197604906
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85087(a)(3)

Building and Grounds

(3) No room commonly used for other purposes shall be used as a bedroom for any person. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/18/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator agreed to submit a new facility sketch with the additional room for live-in staff.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Nichelle Gillyard

LICENSING EVALUATOR NAME:

Huma Rahimi

LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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