197607384-2-25-2024-29-AS-EPEI-D2SSY9-20240225131709

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607384
Report Date: 02/25/2024
Date Signed: 02/25/2024 01:17:43 PM

Document Has Been Signed on 02/25/2024 01:17 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CASA COSTELLO		FACILITY NUMBER:	197607384
ADMINISTRATOR:	MARIA ELENA SHINN		FACILITY TYPE:	740
ADDRESS:	8347 COSTELLO AVE.		TELEPHONE:	(818) 892-8853
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	4	CENSUS: 4	DATE:	02/25/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Maria Shinn, Licensee		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 02/24/2024. At 10:30 a.m., the LPA met with the Licensee and explained the reason for the visit. RECORD REVIEWS: Between 10:36 a.m. and 11:51 a.m., the LPA conducted a file review for all four (4) residents and observed the following: appraisals, care plans, medical records, admissions agreement, consent forms. All resident records were up to date. At 12:10 p.m., P&I money was reviewed. Starting at 11:52 a.m., the LPA conducted a review of medication and medication documentation with staff for all four (4) residents and observed that all medications were properly documented and assisted with as prescribed. At 12:12 p.m., the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:15 p.m., hot water measured at 105.2-degree Fahrenheit. Medications are centrally stored and located inside a locked cabinet in the kitchen. The laundry units are located inside the kitchen. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms, three (3) for resident use and one (1) for staff use and three (3) bathrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA COSTELLO	FACILITY NUMBER: 197607384
	VISIT DATE: 02/25/2024

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RESTROOM: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 12:17 p.m., the hot water temperature tested at 105.0-degree Fahrenheit.

OUTDOOR SPACE: At 12:20 p.m., the LPA observed the back patio. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside the locked storage rooms.

COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the fire extinguishers to be fully charged and last serviced on 12/21/2023. Signs are posted throughout the facility to promote handwashing, and cough/sneeze etiquette. At 12:23 p.m., smoke alarms and carbon monoxide detectors were tested and functioning properly.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2024

LIC809 (FAS) - (06/04)

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