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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606176
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:11:27 PM

Document Has Been Signed on 05/11/2022 02:11 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:KATHYANN HOME INC.FACILITY NUMBER:
197606176
ADMINISTRATOR:LA SEAN JAMESFACILITY TYPE:
735
ADDRESS:11906 KATHYANN STREETTELEPHONE:
(818) 201-7225
CITY:LAKEVIEW TERRACESTATE: CAZIP CODE:
91342
CAPACITY: 4CENSUS: 4DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Louise McMillonTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced annual required visit. LPA met with facility staff and explained the reason for this visit.

A tour of the physical plant was done from 12:30-12:50pm and the following was noted:

Facility has three (3) bedrooms and two (2) bathrooms. There is no body water in the facility.
Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 115°F and within the required range..
Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of obstructions during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet in the garage.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is observed to be within the required range.
Garage is attached to the house. Garage is also used as laundry room and storage. Cleaning solutions and laundry detergents are observed kept in the locked cabinet in the garage.
No deficiencies cited. Exit Interview conducted
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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