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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608120
Report Date: 12/07/2023
Date Signed: 12/07/2023 11:59:40 AM

Document Has Been Signed on 12/07/2023 11:59 AM - 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, LLCFACILITY NUMBER:
197608120
ADMINISTRATOR:ROSANNA TOMENENGFACILITY TYPE:
735
ADDRESS:16055 NAPA STREETTELEPHONE:
(818) 830-7383
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 3DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rosanna Tomeneng, AdministratorTIME COMPLETED:
12:20 PM
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At 10:30am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA were greeted by the Staff #1, Vicenta Vergara, who granted access to the facility. Administrator arrived shortly after and LPA explained the reason for the visit. Physical tour was conducted and LPA observed the following:

Kitchen: At approximately, 10:35am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a staff room, located by the kitchen, and inaccessible to clients in care. Fire extinguisher in the kitchen, was last serviced on 05/5/2023.

Medications: At approximately, 10:40am LPA observed medications are centrally stored and locked in the kitchen cabinet.

Bedrooms: Facility has six (6) bedrooms, four (4) of which are designated for clients use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Staff bedrooms were observed to be locked and inaccessible to clients in care.

Bathrooms: LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. Hot water temperature measured at 110.3°F.


Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CCLE HOME CARE, LLC
FACILITY NUMBER: 197608120
VISIT DATE: 12/07/2023
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Common Areas: The facility maintains a comfortable temperature at 69°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture and the fireplace is adequately screened. No obstructions and or tripping hazards throughout the facility. Laundry is located in the hallway, by the kitchen and all detergents were observed to be locked and inaccessible to clients in care. Second fire extinguisher was located upstairs in a hallway.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:50am they were tested and observed to be operational. Carbon monoxide was located in the kitchen and was also tested and observed to be operational.

Outside areas: At approximately, 11:00am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA observed two (2) storage sheds in a backyard and both were kept locked and inaccessible to clients in care. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients.



Between 11:05am to 12:00pm, LPA reviewed records of three (3) clients and two (2) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during todays visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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