197608133-5-10-2024-31-AS-MCAA-D55Q4K-20240510115028

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608133
Report Date: 05/10/2024
Date Signed: 05/10/2024 11:50:37 AM

Document Has Been Signed on 05/10/2024 11:50 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:	EASTER SEALS SOUTHERN CALIFORNIA DEMPSY HOME		FACILITY NUMBER:	197608133
ADMINISTRATOR/ DIRECTOR:	LISA M. MCDONALD		FACILITY TYPE:	735
ADDRESS:	11324 DEMPSEY AVE		TELEPHONE:	(818) 363-6241
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 4		CENSUS: 3	DATE:	05/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:02 AM
MET WITH:	Sarah Ajayi, Barbara Pacheco, Danny Tapia		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Sarah Ajayi and Stella Ngaka, and explained the reason for the visit. Administrators Barbara Pacheco and Danny Tapia joined shortly after. At 09:15am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected. There are two carbon monoxide detectors. One by the kitchen and one in the living room. Both are functional. The fire extinguisher is located by the front entrance. The charge date is 02/04/2024. Earthquake and emergency drill was last conducted in April 2024. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. There is also a medication cabinet in the kitchen for over the counter and overflow PRN medications. Medication cabinet in the kitchen was locked during the visit. Bedrooms: There were four (4) bedrooms designated for the residents. Each room is for private use. The rooms that are currently occupied for resident use were observed to be properly furnished with appropriate beddings and linens with sufficient lighting. Exit doors in resident rooms were clear of obstruction. Auditory alerts in resident rooms were tested and are functional. Bathrooms: There are three (3) bathrooms. Two (2) are designated for residents' use. One (1) bathroom is reserved for staff. Both bathrooms designated for resident use were properly supplied and had functional fixtures. Hot water temperature was measured at 115 degrees Fahrenheit. No cleaning supplies observed present and accessible.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA DEMPSY HOME	FACILITY NUMBER: 197608133
	VISIT DATE: 05/10/2024

NARRATIVE

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Common Areas: These included the living room and dining area. The common areas were properly furnished. The living room furniture was observed maintained and in good repair. Floors were clean. The fireplace, is non-functional, and was observed to have a glass and screen door. The dining room table is large enough to seat up to six (6) residents. The auditory alarms on all exit doors were on and functional at the time of the visit.

Surrounding Grounds: Entry/exits and passageways to the front and backyard were clean, maintained and free of obstruction. There was furniture appropriate for outdoor use. There are two storage buildings that was checked and observed locked. Exterior gates to the front and back yards were checked to insure there are no locks.

Laundry: The laundry area is located adjacent to the kitchen. Cleaning supplies and detergents are maintained locked in a cabinet above the washer/dryer. Laundry room also has a storage for emergency food supplies. Door to laundry area is kept locked.

Office/Staff Work Station: There is an office, by the backdoor, where staff and resident files are kept and locked. Additional cleaning supplies kept here. Office is kept locked when not in usre. There is an additional staff work station, located at the corner by room #1 where resident medication/centrally stored is kept and locked.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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