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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608341
Report Date: 08/20/2024
Date Signed: 08/20/2024 01:17:28 PM

Document Has Been Signed on 08/20/2024 01:17 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BALCOM HOMEFACILITY NUMBER:
197608341
ADMINISTRATOR/
DIRECTOR:		MERCEDE SHAMLOFACILITY TYPE:
735
ADDRESS:7767 BALCOM AVETELEPHONE:
(818) 342-1001
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Mercede Shamlo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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At 10:15 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff and the Administrator was contacted via phone. The Administrator arrived shortly after and LPA explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

It is a single story building with four (4) bedrooms, two (2) bathrooms, kitchen, garage, common areas, office, and outdoor areas. It has an approved fire clearance for four (4) nonambulatory clients, of which one (1) may be bedridden in Bedroom # two (2). The facility has a telephone (land line), and cellular phone for clients and staff use.

Kitchen: At approximately, 11:00 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum one (1) week and perishable for two (2) days at the facility. All knives and sharps observed to be locked under the kitchen sink. LPA observed a fully charged fire extinguisher in the kitchen by the fridge last serviced on 08/05/2024.

Medications: At approximately, 11:02 AM LPA observed medications are centrally stored and locked in a kitchen cabinet. A fully stocked First Aid kit was kept in the medication cabinet.

Bedrooms: LPA observed total of four (4) bedrooms designated for clients use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff. An office at the end of the hallway was locked and contained client and staff files.

Bathrooms: LPA observed two (2) bathrooms and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed that each client has separate caddy locked in the bathroom cabinets. LPA observed appropriate grab bar and client's bathroom had non-skid mat. Hot water temperature measured at 118.4°F.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BALCOM HOME
FACILITY NUMBER: 197608341
VISIT DATE: 08/20/2024
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Common Areas: The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The garage was locked and contained an extra refrigerator and freezer, paper supplies, incontinence supplies, and PPE. The garage was also used as a laundry room and LPA observed all the laundry detergent and other cleaning supplies to be locked and inaccessible to clients in care. LPA measured the room temperature to be 72°F. A fireplace in the living room was inaccessible and covered appropriately. Clients and staff were doing activities in the living room during the visit. Toys, games, art materials, and television were provided.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 11:19 AM they were tested and observed to be operational. Carbon monoxide was located by the garage entrance and was also tested and observed to be operational.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture and exercise equipment in good repair with a covered patio for clients use. All emergency exit paths were free from obstructions. Exit gates were unlocked with inward facing latches.

Between 11:25 AM to 12:50 PM, LPA reviewed records of two (2) 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 today’s visit.

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

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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