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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606620
Report Date: 06/10/2024
Date Signed: 06/10/2024 07:26:23 PM

Document Has Been Signed on 06/10/2024 07:26 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:DORIS HOME IIFACILITY NUMBER:
197606620
ADMINISTRATOR/
DIRECTOR:		DORIS DUONGFACILITY TYPE:
735
ADDRESS:7812 COMANCHE AVENUETELEPHONE:
(818) 773-8258
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 4CENSUS: 4DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Doris DuongTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 06/10/24, 9:45AM Licensing Program Analyst (LPA) Raymond Comer conducted an unannounced Annual visit at the Facility. LPA met with caregiver who contacted the Facility Administrator, Doris Duong, and reason for the visit was stated.

Facility is licensed as a single-story residence for four (4) ambulatory, of which, none may be bedridden. Facility has four (4) private resident bedrooms, and two (2) bedroom space designated for Staff. Total of three (3) bathrooms.

At 10:00AM, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Resident records: Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.

Staff records: Staff files were reviewed. Criminal record clearances, Health Screening, Employee Rights Records were present and Staff are associated to this facility. Staff records appear to be complete and current.

Physical plant: At 12:05pm, LPA inspected facility for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted in the bathroom and throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 116.1°F. within the required range.

[LIC 809C -Continued]
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DORIS HOME II
FACILITY NUMBER: 197606620
VISIT DATE: 06/10/2024
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Fire Detection/Protection system is present in the facility. Multiple smoke alarms are installed, hardwired, and interconnected. Carbon monoxide alarm is present and installed. Smoke and Carbon monoxide detectors were tested and function properly. LPA observed one fire extinguisher located in the dining area with service date: 10/14/2023.

Kitchen: At 12:30 PM, LPA observed kitchen as clean, equipped with a functional stove, multiple appliances, with adequate supply of perishables and non-perishable food. Food is observed as properly labeled and stored. Kitchen cabinets store dishes, plastic, paper goods and utensils. Knives and sharps are secured in a locked drawer and inaccessible to residents.

Medications are stored in a secured locked cabinet in the Kitchen area and are inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. A First Aid kit is complete and stored in the medication cabinet.



Garage\Laundry: Garage is attached to the house and was observed to be locked an inaccessible to residents. Garage is a storage for PPE and various other supplies. Washer and Dryer machines are in the garage. Laundry soaps and other cleaning agents are stored and in a locked cabinet. Linen storage observed to have adequate supply of linen and towels.

Commons: LPA observed all common areas of the facility, including the resident dining area. LPA observed common areas to be clean, organized, with furnishings in good condition.

Bedrooms are observed as clean with sufficient lighting, properly furnished with bedding, dressers, close closets, linens, at least one chair, and night stand.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 116.1°F. Within the required range.

Outdoor (backyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility.

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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