197608120-5-4-2022-31-AS-MCAA-CE4TL8-20220504144907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608120
Report Date: 05/04/2022
Date Signed: 05/04/2022 02:49:35 PM

Document Has Been Signed on 05/04/2022 02:49 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CCLE HOME CARE, LLC		FACILITY NUMBER:	197608120
ADMINISTRATOR:	ROSANNA TOMENENG		FACILITY TYPE:	735
ADDRESS:	16055 NAPA STREET		TELEPHONE:	(818) 830-7383
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 3	DATE:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Rosanna Tomeneng		TIME COMPLETED:	03:00 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	A Required One (1) year Annual- Infection Control visit was conducted today by Licensing Program Analyst (LPA) Michael Cava. LPA met with the administrator, Rosana Tomaneng and stated the purpose of the visit. The facility has a census of three (3), but all residents were out either at work or on their own activity. The tour of the physical plant was conducted at 9:00am and the following were noted: The front/main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear a mask and must be screened. The screening area is located near the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA Cava was screened by staff upon entry. All staff were observed to be wearing a mask. Including the administrator, there were two (2) staff on duty. The facility submitted a Mitigation Plan. Signs to wear a mask and other COVID 19 prevention protocol signs were posted on the walls. 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 covers. The facility has a sufficient supply of PPE in the storage room. Resident rooms: Facility has six (6) bedrooms. Two (2) rooms are for staff use. Four (4) private rooms are designated for client use. All four met regulation. LPA observed rooms to have appropriate bedding sheets, pillowcase, mattress pad, and blanket which are in good condition. There is at least one chair, night stand and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CCLE HOME CARE, LLC	FACILITY NUMBER: 197608120
	VISIT DATE: 05/04/2022

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
26
27
28
29
30
31
32

Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 112 degrees F. LPA observed the appropriate non-skid mat in each bathroom. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene items which is provided by the Licensee.

Common Areas: LPA toured all common areas of the facility. LPA observed common areas to be clean and furniture in good repair. The facility maintains a comfortable temperature at 78 degrees F. LPA observed two (2) fire extinguishers. One in the living room and one in the hallway near resident rooms on the second floor. The last service date was 4/11/2022. The smoke and carbon monoxide detectors are operational. The smoke alarms are hard wired, while the carbon monoxide alarm is battery operated. There are no issues with Fire Clearance.

Outside areas: LPA toured the outside area of the facility. Passageways were safe and clear of obstruction. There are no bodies of water.

The garage is attached to the home. It is kept locked and inaccessible to clients. The garage is used as storage space.

Food Inspection: LPA conducted a food inspection tour. LPA observed there to be sufficient stock of two- perishable and seven-day non-perishables foods. Snacks and beverages are available for clients in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides or toxins were stored and locked away.

Laundry: Laundry area is located by the kitchen. Detergent was observed inaccessible to the clients.

Pursuant to CA code of Regulations Title 22 or Health and Safety Code. No deficiencies observed during the day's visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2