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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606869
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:04:57 PM


Document Has Been Signed on 12/05/2023 01:04 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:TYCOON RESIDENTIALFACILITY NUMBER:
197606869
ADMINISTRATOR:YOLANDA VILLANUEVAFACILITY TYPE:
740
ADDRESS:10204 GERALD AVENUETELEPHONE:
(818) 363-3418
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
12/05/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Yolanda VillanuevaTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Tuesday Cabiness arrived to the facility to conduct an unannounced annual inspection. Upon arrival LPA met with Licensee/Administrator Yolanda Villanueva and the informed her the reason of the visit. LPA observed residents in the living and dining room watching TV. LPA also observed an additional staff working with Administrator. There were Licensing and COVID signs posted throughout the facility.

The annual inspection consisted of the following: Food Inspection: LPA observed there was a sufficient stock of (7) day non-perishable foods; but facility did not have a sufficient supply of (2) day perishable food. LPA also observed food was not properly wrapped and freezer burned. A technical violation will be issued. Sharps and medications are centrally stored in a locked area. Garbage can has a tight-fitting lid in the kitchen. Fire extinguisher was fully charged. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature. Facility has an attached garage which can be accessed from the living room and the outside. Garage is utilized for supply storage; washer and dryer machine. Residents Rooms: There are four (4) bedrooms of which one (1) is designated for staff use. All the four (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. Bathrooms: There are two (2) bathrooms in the facility. LPA observed all bathrooms to have grab bars and non-skid mats. Hot water measured at 114.8 Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the ground. Smoke alarms and carbon monoxide detectors were operating correctly. Fire extinguisher checked and fully charged. First aid kit was fully equipped. All exits had alarms, were functioning properly. Back yard had clear passageways, and free from obstruction. Gates were unlocked and easily to access. Medications were locked in a cabinet, and centrally stored record was accurate and complete. Client and staff files reviewed; proper documentation observed. Technical Violation issued, and copy of report provided

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
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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