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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608245
Report Date: 10/19/2024
Date Signed: 10/19/2024 03:56:53 PM

Document Has Been Signed on 10/19/2024 03:56 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:LOUISE HOUSE 2FACILITY NUMBER:
197608245
ADMINISTRATOR/
DIRECTOR:		JULIANN BARBERFACILITY TYPE:
735
ADDRESS:6455 TUSCAN COURTTELEPHONE:
(661) 526-3983
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 6DATE:
10/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Janine Sanchez - StaffTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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An unannounced One (1) year required visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Janine Sanchez who called the Licensee Wayne White and explained the purpose of the visit. Mr. White designated Ms. Sanchez to sign the report. This is a North Los Angeles Regional center (NLARC) vendored facility Level III.

LPA conducted physical plant tour inside and out at 12:43 PM. During the tour, LPA observed that the facility has four (4) bedrooms and two (2) bathrooms. There is no body of water in the facility. This facility is fire cleared for six (6) ambulatory residents.

The front main door is the only entrance being utilized at the facility. 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 indoors. 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 109.4°F to 115.6°F. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2024
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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LOUISE HOUSE 2
FACILITY NUMBER: 197608245
VISIT DATE: 10/19/2024
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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 cabinet below the sink.
Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguisher was observed to be located by the kitchen. Fire extinguisher was observed to be operable and last bought on 10/19/24. 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 in the supply room inside the staff room closet. Knives and sharps are locked and secured in a kitchen drawer.
Garage is located adjacent to the house and has separate entrance. Laundry room is located on the way to the garage. Laundry room was observed to be locked during visit. Garage is also used as frozen food, emergency supplies and tools and old equipment storage.
Client records. All six (6) client records were reviewed. Clients record appeared to be 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 09/18/24. 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: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC809 (FAS) - (06/04)
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