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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604906
Report Date: 10/28/2024
Date Signed: 10/28/2024 12:07:53 PM

Document Has Been Signed on 10/28/2024 12:07 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:DORIS' RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197604906
ADMINISTRATOR/
DIRECTOR:		DORIS DUONGFACILITY TYPE:
735
ADDRESS:8012 NEWCASTLE AVENUETELEPHONE:
(818) 774-9706
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Doris Duong, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with the Administrator Doris Duong, and disclosed the reason for the visit. LPA and Administrator 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 clients.

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 10:05 AM, LPA and Administrator 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. 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.

MEDICATIONS: LPA observed the medication locked and inaccessible to clients in care in locked kitchen cabinet. There was a complete first aid kit available in the staff bedroom.

Bedrooms:. There are four (4) bedrooms designated for clients use. There are two (2) bedrooms designated for staff use. Both staff bedrooms were 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.

Bathrooms: The facility has two (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 10:26 AM. LPA measured the water temperature in the shared bathroom to be 109.8 degrees Fahrenheit.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 10/28/2024
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COMMON AREAS: These included the TV and activity room which were equipped with living room furniture, a television, tables and chairs. There is a fireplace with a screen and a glass slide. It is non-operational. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards. At 10:32 AM, LPA observed a fully charged fire extinguisher in the hallway and last purchased on 10/28/2024.

SURROUNDING GROUNDS: 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 10:45 AM, LPA tested the smoke detector and carbon monoxide detectors to be operational.


Between 11:00 AM to 12:15 PM, LPA reviewed records of four (4) clients and two (2) staff. Clients and staff records appeared to be complete and updated

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.


SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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