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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608281
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:17:31 PM

Document Has Been Signed on 09/06/2024 02:17 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:SHY HOMEFACILITY NUMBER:
197608281
ADMINISTRATOR/
DIRECTOR:		HILEWNA TAMRATFACILITY TYPE:
735
ADDRESS:38460 YUCCA TREE STTELEPHONE:
(213) 253-8551
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:HILEWNA TAMRAT TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by the Administrator, Hilewna Tamrat. The facility is licensed as an adult residential facility to serve two ambulatory and two non-ambulatory clients. .

LPA and the Administrator began the tour of the facility at 8:45 am until 9:15 am. LPA observed the following:

Living Room/Dining Room– LPA Spaeth observed the living room comfortable seating and the dining room area contained a dining room table and chairs. A fire extinguisher is located in the dining room. The resident files were locked in a closet.

Kitchen - LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The fire extinguisher is located in the kitchen. The knives were locked in a kitchen drawer. The medications and the first aid kit were locked in a kitchen cabinet. The water temperature was tested at 9:00 am and the temperature was 108.0 F.

Bathrooms – LPA Spaeth observed the bathrooms contained hand soap, paper towels, and a trash can.

Bedrooms – LPA Spaeth observed there are three client bedrooms in the facility. The bedrooms contained bed, linens, night stand ,chair and night lamp.

Laundry Room – LPA Spaeth observed the laundry room was locked and contained the washer/dryer, and laundry detergent.

cont'd 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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: SHY HOME
FACILITY NUMBER: 197608281
VISIT DATE: 09/06/2024
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Garage - LPA observed the emergency water, an additional refrigerator and freezer were located in the garage.

Backyard – LPA Spaeth observed comfortable seating in a shaded area. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 9:55 am and were operable.

LPA viewed clients' files at 9:15 am until 9:35 am. LPA reviewed client's P&I at 9:35 am until 9:45 am. LPA reviewed staff records at 9:35 am until 10:00 am. LPA Spaeth conducted the medication review at 10:15 am until 10:40 am

There are no deficiencies to report at this time.



Exit interview conducted, and a copy of the signed report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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