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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608370
Report Date: 11/28/2022
Date Signed: 11/28/2022 11:16:30 AM

Document Has Been Signed on 11/28/2022 11:16 AM - 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:NATIONAL SUPPORT SERVICES HOME IIFACILITY NUMBER:
197608370
ADMINISTRATOR:LORA MAY TEMPORAL PANAFACILITY TYPE:
735
ADDRESS:15842 VINCENNES STREETTELEPHONE:
(626) 926-7186
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:LORA MAY TEMPORAL PANATIME COMPLETED:
11:00 AM
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On 11/28/22 Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection. Upon arrival LPA was greeted by staff and LPA met the Administrator. Administrator notified LPA that they currently have one covid positive client and are awaiting results for other clients who display symptoms. The purpose of the visit was explained. Due to covid positive clients, LPA conducted a quick physical plant tour, and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. LPA observed a visitors screening station by the entrance. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medications are centrally stored in a locked cabinet. Common Areas: All common areas were observed to be clean and properly furnished. Facility’s temperature at the time of the visit was 72 F. Client Rooms: Facility has four (4) bedrooms for client use, three of which were toured and appear to be clean and properly furnished. All rooms have adequate lighting and furniture. Bathrooms: There are two (2) bathrooms in the facility. LPA observed all bathrooms to be cleaned and appropriate grab bars were installed. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water on the ground.

LPA spoke to the Administrator about reporting requirements regarding covid clients and staff. No deficiencies cited. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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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