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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606176
Report Date: 07/14/2024
Date Signed: 07/16/2024 08:34:57 AM

Document Has Been Signed on 07/16/2024 08:34 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KATHYANN HOME INC.FACILITY NUMBER:
197606176
ADMINISTRATOR/
DIRECTOR:		LA SEAN JAMESFACILITY TYPE:
735
ADDRESS:11906 KATHYANN STREETTELEPHONE:
(818) 201-7225
CITY:LAKEVIEW TERRACESTATE: CAZIP CODE:
91342
CAPACITY: 4CENSUS: 3DATE:
07/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:53 AM
MET WITH:Louise McMillon - Co AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with co Administrator Louise McMillon and explained the reason for the visit. This is a North Los Angeles Regional Center vendored facility Level IV-G.

A tour of the physical plant was conducted at 11:10 AM and the following was noted:

The main door is the only entrance being utilized at this facility. Screening area is located immediately after entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan.

Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

Facility has three (3) shared client bedrooms and two (2) bathrooms. There is no body water in the facility. The facility is fire cleared for four (4) non-ambulatory residents.

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 was measured at 118.6°F.

(continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KATHYANN HOME INC.
FACILITY NUMBER: 197606176
VISIT DATE: 07/14/2024
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(continued from LIC 809)

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.
Fire extinguisher There was a fire extinguisher in the facility located in the kitchen. Extinguisher was observed to be operable and last check on 07/28/23. Dual Smoke/Carbon monoxide alarms are tested and observed to be operable. Smoke alarms are inter connected and both hardwired and battery operated.

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.



Medication was observed to be inaccessible and stored in a secured cabinet. There are two (2) complete First Aid kits kept in the medication cabinet.

Staff records were checked. Staff present has criminal record clearances and associated to this facility.
Staff records appear to be complete and current. Client records were also reviewed and appeared to be complete and current.

Disaster drill was last conducted on 07/06/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2024
LIC809 (FAS) - (06/04)
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