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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606424
Report Date: 02/28/2022
Date Signed: 02/28/2022 07:04:11 PM

Document Has Been Signed on 02/28/2022 07:04 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:HAZELWOOD MIGHTY HOMESFACILITY NUMBER:
197606424
ADMINISTRATOR:ELIZABETH A. DAGOYFACILITY TYPE:
740
ADDRESS:1557 HAZELWOOD AVENUETELEPHONE:
(323) 257-1487
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY: 6CENSUS: 3DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Elizabeth DagoyTIME COMPLETED:
05:08 PM
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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility on 02/28/2022 at 2:46pm to conducted a One (1)year Required Infection Control visit. LPA meet with staff Luzzy Dugoy and explained the purpose of this visit.
A tour of the physical plant was conducted at 2:51pm and the following was observed: At the time of the inspection, the facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) posted. The PPE screening station is located in the living room area on a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. One (01) hospice resident and waiver for (01).

The facility has an approved mitigation plan on file.

Kitchen: At 2:54pm LPA observed an adequate supply of perishables and non-perishable food located in the fridge and freezer. The Fire Extinguisher located on the wall next to the exit door which has a service tag dated 03/31/2021. LPA observed sharps to be locked and stored in a cabinet near the exit door to the back of the kitchen. LPA observed toxins, cleaning solutions, and soap stored and locked underneath the kitchen cabinet sink. At 3:08pm the fire alarm system was tested and observed to be working, it is hard wired and interconnected. The carbon monoxide detector is located on the wall in the kitchen. Appliances observed to be in good repair and operational. LPA observed fresh

Storage Rooms: LPA observed a storage room at 3:17pm located in the kitchen near the exit door, to be storing dry/hot cereal, can goods(soups, chili, beans, sauces, etc), snacks, paper towels and forks/spoons.

Bedrooms: The facility has four (04) bedrooms, which one is designated as staff room to be storing boxes of personal items. At 3:25pm LPA observed all bedrooms to be clean and clear from obstruction, properly furnished, sufficient lighting, appropriate bedding and linens. Trash cans observed to have attached lid.

(Continued on LIC 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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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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: HAZELWOOD MIGHTY HOMES
FACILITY NUMBER: 197606424
VISIT DATE: 02/28/2022
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Bathrooms: At 3:31pm LPA observed the bathrooms to be clean and in good repair. LPA observed the appropriate grab bars in and around the toilet and shower also non-skid mats are located in the shower area. The water temperature measured 110.8 between 112.2 degrees Fahrenheit. Hand towels and wash clothes are not shared
Living, dining room and common areas: Observed to be appropriately furnished with tables and chairs and adequate lighting. The facility maintains a comfortable temperature at 77 degree Fahrenheit. Observed to be clean and in good repair.
Medications: At 3:42 pm LPA observed the medication cupboard locked and stored near the bathroom and living room. The facility first aid kit and manual located on top of the medication cupboard. LPA observed extra towels and linens stored on shelves mounted into the wall next to the medication cupboard.
Backyard: At 3:48 LPA observed the backyard and surrounding area of the facility to be clean and clear from debris. A covered canopy area with tables and chairs for lounging, the front porch area is shaded with chairs for lounging. A detached garage observed to be locked and storing PPE, incontinent supplies, and personal items inaccessible to residents. No bodies of water observed on the premises.
Laundry Room: LPA observed the washing machines located outside in the back of the facility at 3:51pm observed to be clean and clear from obstruction. Laundry soap, toxins and cleaning supplies are stored outside on a shelf near the laundry machines, inaccessible to residents.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
LIC809 (FAS) - (06/04)
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