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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607183
Report Date: 09/10/2024
Date Signed: 09/10/2024 01:04:04 PM

Document Has Been Signed on 09/10/2024 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AVENUE "H" GUEST HOME, INC.FACILITY NUMBER:
197607183
ADMINISTRATOR/
DIRECTOR:		JOEL FLETCHERFACILITY TYPE:
735
ADDRESS:3640 AVENUE H-13TELEPHONE:
(661) 916-7507
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Belinda HicksTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Belinda Hicks for an unannounced one (1) year Required visit for this facility. LPA arrived at 10:10 am and was greeted and granted access by staff. All clients were at day program. The Administrator arrived shortly after. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed infection control plan (approved on 07/14/2022) to make sure the licensee was following current infection control recommendations. Upon entry staff took LPA’s temperature and asked LPA to answer covid symptom questions as well as sign in.

A tour of the physical plant was conducted with Administrator at 10:30 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for four (4) ambulatory.

Due to technical difficulties LPA did not use Tool Kit on this annual.

Kitchen: LPA conducted a tour of the kitchen at 10:30 am, LPA observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects, medications, and first aid kit being locked and inaccessible to clients in care.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 72°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:40 am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 04/02/24.

Continued LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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: AVENUE "H" GUEST HOME, INC.
FACILITY NUMBER: 197607183
VISIT DATE: 09/10/2024
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Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, chair, and sufficient lighting for each client. All window screens were in good condition.

Bathrooms: At 10:45 am LPA observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested, and measured within regulation at 105.0 degrees F.

Laundry: LPA observed no chemicals/hazardous items in the laundry room.

Physical environment: LPA toured the outside area of the facility at 10:50 am. LPA observed appropriate outdoor furniture, with an umbrella for shade. No bodies of water on the premises.

Garage: LPA observed the garage to be attached to the facility and currently being used for extra food storage, storage for detergents, and PPE supplies.

Administrative: Annual fee is current. LPA collected LIC500, Liability and Bond Certificate, Administrator Certificate and Client roster.

Staff/Client Interviews: At 11:00 am LPA conducted interview.

Staff/Client Records: At 11:20 am LPA conducted file reviews.

Medication: At 12:45 pm LPA and Administrator reviewed medication and medication logs.

No citations issued. Exit interview conducted. Copy of report provided to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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