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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606424
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:26:43 PM

Document Has Been Signed on 03/19/2025 03:26 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:HAZELWOOD MIGHTY HOMESFACILITY NUMBER:
197606424
ADMINISTRATOR/
DIRECTOR:
ELIZABETH A. DAGOYFACILITY TYPE:
740
ADDRESS:1557 HAZELWOOD AVENUETELEPHONE:
(323) 257-1487
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator,Luzzy Dagoy & Licensee/Administrator Elizabeth DagoyTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At 9:30a.m., Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection to the facility. LPA met with Administrator and explained the reason for the visit. At approximately 9:55a.m., Licensee/Administrator joined today’s visit.

At 10:00a.m., Administrator and LPA conducted physical plant tour inside and out. During the tour, LPA observed that the facility is a single -story home in a residential community. The front main door is the only entrance being utilized at the facility, it has four (04) bedrooms and two (02) bathrooms. One (01) private bedroom and two (02) empty rooms designated for residents, and one (01) bedroom for live in staff. Fire/Earthquake drill was last conducted on 02/20/2025. Required posting observed displayed in the facility living room (complaint hot line poster, personal rights, etc). Temperature of facility wall thermostat is observed and set to 72 degrees Fahrenheit. 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. No obstructions and or tripping hazards throughout the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. Furniture in common area was observed to be in good repair. Residents dining table fits six (06) residents.
Bedrooms were toured and observed to be clean and properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Linen storage was also checked and observed to have ample supply of clean linen, comforters, and towels in facility. Staff bedroom is designated only for live in Administrator.

(continued to LIC 809-C)

Naira MargaryanTELEPHONE: (818) 596-4368
Antonia Alvizar-EttimaTELEPHONE: (818) 383-6108
DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAZELWOOD MIGHTY HOMES
FACILITY NUMBER: 197606424
VISIT DATE: 03/19/2025
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(continued from LIC 809)

Every bedroom, hallway area and kitchen has smoke detectors that are functional. Bathrooms were observed to be clean, sanitary and with necessary supplies. The appropriate grab bars and mats in the shower. Hot water temperature measured at a range of 110.7°F to 118.0°F and within the required range. Resident’s personal hygiene supplied are kept in their personal space. Towels and washcloths are not shared. Kitchen Area is observed to be clean and sanitary. Sharps are locked and stored in a cabinet near the exit door to the back of the kitchen. Toxins, cleaning solutions, and soap stored and locked underneath the kitchen cabinet sink. Fire extinguishers were observed to be located in the kitchen area. Fire extinguishers were observed to be operable with service date of 02/07/2025. Food: LPA observed at least two (02) days perishable and seven (07) days non-perishable food at the facility that is properly stored. Frozen foods are wrap and stored properly as well. Food storage and preparation areas are clean. Medication was observed to be locked in a chest drawer. Stored in the dining area inaccessible to residents in care. In the hallway, there is a locked closet with a complete first aid kit, manual and staff folders. Garage is detached from the house and observed to be locked and inaccessible to residents. The garage storages extra supplies, laundry detergents and cleaning agents. Laundry Room: LPA observed washer and dryer machines located outside on the back of the facility. LPA 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. Surrounding Grounds The front grounds of the facility are well landscaped. All passageways and stairways were observed to be clear from obstruction. A covered canopy area with tables and chairs for lounging, the front porch area is shaded with chairs for lounging. The outdoor area was enclosed, and no bodies of water were observed on the premises. Resident Record. One (01) resident record were reviewed. Resident record is complete and current at this time.

Staff Records were also reviewed they all have criminal record clearances and associated to this facility. Staff on duty do not have current cardiopulmonary resuscitation (CPR) and first aid training. Administrator's certificate was observed to be current.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed cited on LIC809-D during the visit.

Exit Interview Conducted / A Copy of the Report was provided to Licensee/Administrator.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-EttimaTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/19/2025 03:26 PM - It Cannot Be Edited

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: HAZELWOOD MIGHTY HOMES

FACILITY NUMBER: 197606424

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above staff on duty do not have cardiopulmonary resuscitation (CRP) and first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Licensee/Administrator will schedule cardiopulmonary resuscitation (CPR) and first aid training. Licensee/Administrator will email CCL training schedule date by POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Naira MargaryanTELEPHONE: (818) 596-4368
Antonia Alvizar-EttimaTELEPHONE: (818) 383-6108

DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025

LIC809 (FAS) - (06/04)
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