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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608341
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:24:12 PM

Document Has Been Signed on 11/30/2023 12:24 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:BALCOM HOMEFACILITY NUMBER:
197608341
ADMINISTRATOR:MERCEDE SHAMLOFACILITY TYPE:
735
ADDRESS:7767 BALCOM AVETELEPHONE:
(818) 342-1001
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mercede Shamlo, Administrator TIME COMPLETED:
12:50 PM
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At 10:0am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with Rita Dafrique, Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPA explained the reason for the visit.

At 10:05am LPA conducted a tour of the physical plant and observed the following:

Facility is an Adult Residential Care Facility which was licensed for capacity of four (4) of which four (4) non-ambulatory and one (1) bedridden client. Facility has an office, four (4) bedrooms designated for residents use, two (2) bathrooms and LPA was informed that the facility has awake staff at night. LPA was able to tour the home and did not observe any immediate health and safety concerns. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a temperature of 70°F. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. The hot water temperature measured at 113.7°F. Extra towels and linens were readily available. The fire extinguisher was observed in the kitchen area and was last serviced on 09/15/2023. Laundry is located in an attached garage, and LPA observed all chemicals and detergents are kept locked and inaccessible to clients. LPA observed a clean covered patio and backyard furniture to accommodate the four (4) clients. Between 11:00am to 12:00pm, LPA reviewed records of four (4) clients and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this 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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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