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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607398
Report Date: 12/10/2023
Date Signed: 12/10/2023 04:10:13 PM

Document Has Been Signed on 12/10/2023 04:10 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:VIP ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197607398
ADMINISTRATOR:TEKOA HUEYFACILITY TYPE:
735
ADDRESS:37636 RUBY LANETELEPHONE:
(661) 533-3986
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 4DATE:
12/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Jermarcus Dumas - Co AdministratorTIME COMPLETED:
04:09 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Jose Alvarenga who called the Co-Administrator Jemarcus Dumas who arrived in ten (10) minutes and explained the reason for the visit. This is a North Los Angeles Regional Center vendored facility Level IV-G.

LPA conducted physical plant tour inside and out at 1:10 PM. During the tour, LPA observed that the facility has four (4) bedrooms and two (2) bathrooms. One (1) bedroom is designated for staff use as an office. There is no body of water in the facility.

The front main door is the only entrance being utilized at the facility. There is a sign on the front door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

The facility had submitted and approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage.

Bedrooms were toured and observed to be clean and appropriately furnished.
Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 111.6°F to 116.7°F. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIP ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197607398
VISIT DATE: 12/10/2023
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions and other toxins were observed to be locked in the locked in the laundry room Knives and other sharps were locked in kitchen cabinet with the medication. Laundry room is located adjacent to the office on the way to the garage. Laundry detergent, cleaning agents and other toxins are kept in the locked laundry room
Food. The facility is observed to have sufficient food supply both perishable and non-perishable for clients. Temperature of facility wall thermostat was set at 75.0°F and observed to be within the required range.
Fire extinguisher was observed to be located in the kitchen. Fire extinguisher was observed to be operable and last bought on 11/28/23. Fire alarms are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector installed in the facility.
Medication were observed to be locked, inaccessible and stored in a kitchen cabinet. There was a complete first aid kit located inside the medication cabinet.
Garage is attached to the facility and has only access through the laundry room which was always locked. Garage is also used as emergency supplies, toxins and tools, old equipment and frozen and emergency food storage.
Client records. All four (4) client records were reviewed. Clients record are complete and current.
Staff records were also reviewed. All staff present records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 10/02/23. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2023
LIC809 (FAS) - (06/04)
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