197608357-12-27-2023-29-AS-SURA-CYWUDK-20231227142941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608357
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:31:12 PM

Document Has Been Signed on 12/27/2023 02:31 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HILLTOP HAVEN #1		FACILITY NUMBER:	197608357
ADMINISTRATOR:	ERWIN DUFFELS		FACILITY TYPE:	740
ADDRESS:	20550 AETNA STREET		TELEPHONE:	(818) 474-9671
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	12/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Tom Stiles		TIME COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 10:25 a.m. The LPA met with staff and explained the reason for the visit. Licensee Tom Stiles arrived shortly thereafter, and the LPA explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals were locked inaccessible in the kitchen cabinets. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food.

BEDROOMS: There are five designated residents’ rooms and one staff room. Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted.

RESTROOMS: Restroom was clean and sanitary with grab bars and non-skid surfaces. At 12:15 p.m. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms.

Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILLTOP HAVEN #1	FACILITY NUMBER: 197608357
	VISIT DATE: 12/27/2023

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COMMON SPACES: Fireplace in the living room was appropriately screened. There was a linen closet in the hallway with extra towels and linens. Fire extinguisher was fully charged and purchased 12/05/2023. The backyard had furniture and a shaded area for residents’ use. The side gate was self-latching; no bodies of water noted. The facility does not have a garage on the property. The washer and dryer are located in the kitchen. Detergent was locked and inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The required postings were observed by the common spaces (entrance and hallway).

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. The garage is where the washer and dryer are held, including additional perishable food items. Cleaning supplies and disinfectants are kept in locked cabinets in the garage.

RECORDS: Records review began at 12:35 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:30 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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