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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606861
Report Date: 01/05/2022
Date Signed: 01/05/2022 03:32:10 PM

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:WEST HILLS CARE HOMEFACILITY NUMBER:
197606861
ADMINISTRATOR:ELAINE BOTEFACILITY TYPE:
740
ADDRESS:22956 INGOMAR STREETTELEPHONE:
(818) 888-9573
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:6CENSUS: 2DATE:
01/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:ELAINE BOTETIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Eleza Jackson conducted an unannounced annual inspection using the Infection Control Tool. Mitigation plan reviewed. A physical tour was conducted and the following was observed: Infection Control: Upon arrival, Caregiver Edelina Igaya?House Manager took LPA Jackson’s temperature and signed in the visitors’ log. Proper signage was observed inside of the facility. House Manager stated they have sufficient PPE supplies for residents and staff. Inspection: LPA Jackson observed there to be sufficient supply of perishable and non perishable foods. Food storage and preparation appear to be clean and inaccessible to pests. Smoke detectors/carbon monoxide tested; deemed to be in operating condition. Fire extinguisher is up to code. Resident rooms: All residents bedrooms were properly furnished with appropriate bedding, sufficient lighting, and the room appeared to be clean. Bathrooms: LPA Jackson observed appropriate hand washing signs posted in the bathroom. Laundry service: LPA Jackson observed that the cleaning products/chemicals are inaccessible to residents. Medications are centrally stored and locked. Outside areas: LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No deficiencies issued. Exit interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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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