197606107-7-15-2023-31-AS-TSMH-CTRUMH-20230715154221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606107
Report Date: 07/15/2023
Date Signed: 07/15/2023 03:42:26 PM

Document Has Been Signed on 07/15/2023 03:42 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	RICH-WAL CENTER #3, THE		FACILITY NUMBER:	197606107
ADMINISTRATOR:	SHIRLEY A. WALKER		FACILITY TYPE:	735
ADDRESS:	15832 BAHAMA STREET		TELEPHONE:	(747) 529-6498
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 5	DATE:	07/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Shirley Walker		TIME COMPLETED:	03:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 10:30 am. LPA Smith was greeted by administrator and disclosed the purpose of the visit. LPA conducted a tour of the physical plant at approximately 10:45 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the kitchen/dining room combination, living room and family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in locked metal locker in kitchen. The resident medications and first aid kit stored in locked metal locker in kitchen and observed to be inaccessible to residents. There is one (1) fire extinguisher attached to dinning room area wall next to the kitchen. Fire extinguisher observed to be charged. Laundry room is in attached garage. The appliances observed to be functional. Toxins stored in locked cabinet in garage and observed to be locked and inaccessible to residents. The facility has a total of four (4) bedrooms, two (2) bathrooms, and half bathroom off kitchen: three (3) shared bedrooms for residents and one (1) bedroom for staff. Two (2) bathrooms are for residents use. (Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RICH-WAL CENTER #3, THE	FACILITY NUMBER: 197606107
	VISIT DATE: 07/15/2023

NARRATIVE

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(Cont from 809)

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hallway closet

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 123.7- and 121.8-degrees Fahrenheit.

Garage: Attached garage has laundry room, two (2) additional refrigerators used as food back stock, and a sufficient supply of PPE’s.

Backyard has the following: one (1) patio table, umbrella (stored in garage when not in use) with sufficient seating for the residents. Patio furniture observed to be in good repair.

There is an in ground empty hot tub in the facility at end of family room. The hot tub doors observed to be locked and inaccessible to residents.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit. Technical Advisory for hairline crack on window glass in half bathroom noted.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

Exit interview conducted/Appeal Rights/Copy of report given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023

LIC809 (FAS) - (06/04)

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