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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606451
Report Date: 04/19/2022
Date Signed: 04/19/2022 11:26:09 AM

Document Has Been Signed on 04/19/2022 11:26 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PARTNERS FOR POTENTIAL, INC.FACILITY NUMBER:
197606451
ADMINISTRATOR:LISA ANN WILLIAMSENFACILITY TYPE:
775
ADDRESS:6255 VAN NUYS BOULEVARDTELEPHONE:
(818) 997-0819
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY: 60CENSUS: 0DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lisa Ann Williamsen, Administrator TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff. At 9:33 a.m., LPA met with the Administrator and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures.

At 9:53 a.m., the LPA, along with the Administrator toured the physical plant areas inside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The day program currently does not have consumers inside the facility. The day program is operating its normal hours of 8:00 a.m. to 2:00 p.m. through remote learning and community outings.

COMMON AREAS: The LPA observed the conference/rest area to be relatively clean and properly furnished. At 9:40 a.m., the LPA observed a missing ceiling tile in the conference/ rest room. The Administrator explained that the roof leaked recently and that a request has been made to fix the leak and to install the ceiling tile. LPA observed the fire extinguishers to be fully charged and last serviced on 10/09/2021.

KITCHEN: At 9:55 a.m., the LPA observed the kitchen area/ staff room. Cleaning solutions, toxins, chemicals and other hazardous items were inaccessible and locked away in the staff room/ kitchen. At 10:07 a.m., hot water measured at 114.8-degree Fahrenheit.

CLASSROOM/OFFICES: LPA observed offices and the classroom, which were observed to have the required furniture and supplies. Inside temperature was maintained at a comfortable level.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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Document Has Been Signed on 04/19/2022 11:26 AM - It Cannot Be Edited


Created By: Emily Peraldi On 04/19/2022 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARTNERS FOR POTENTIAL, INC.
FACILITY NUMBER: 197606451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above as there is a missing ceiling tile and a non-functioning doorbell which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2022
Plan of Correction
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The licensee already requested for the items to be fixed. The licensee will send proof of the fixed doorbell and ceiling tile by POC due date.
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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARTNERS FOR POTENTIAL, INC.
FACILITY NUMBER: 197606451
VISIT DATE: 04/19/2022
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RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition. At 10:06 a.m., hot water measured at 114.1-degree Fahrenheit. Signs are posted throughout all four (4) bathrooms to promote handwashing.

OUTDOOR SPACE: At 9:31 a.m., LPA observed the front door which has a doorbell that does not work. The Administrator explained that a request to fix the doorbell was made. Passageways and stairs to the lobby were free and clear from obstruction.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations,
Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
Exit interview was conducted and report reviewed with Administrator. A copy of the report and appeal rights were provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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