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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608370
Report Date: 11/29/2023
Date Signed: 11/29/2023 12:20:03 PM

Document Has Been Signed on 11/29/2023 12:20 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: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:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Lora May Temporal PanaTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Gina Saucedo met with caregiver Katrina Pana for an unannounced one (1) year required visit for this facility. LPA arrived at 09:05 am at the facility. The Caregiver called the administrator to let them know licensing was here. The Administrator Lora Pana arrived at 9:40am.

Infection control: LPA asked for the staff and client files while waiting for the administrator to arrive. The Infection Control was also obtained and facility mitigation plan while awaiting administrator.

A tour of the physical plant was conducted with the Licensee at 10:30am

Resident Rooms
The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. The bedrooms are single occupied. There is no private bathrooms. One of bathrooms is in between rooms one and three and are shared by three bedridden clients and staff. The other bathroom is located between room three and four and the ambulatory client uses this bathroom. The bathroom temperatures are 108.3 and 117.0 Fahrenheit. Both bathrooms have grab bars, non-skid mats and both bathrooms are wheelchair accessible which is used by three of the clients. One of the clients does not need wheelchair access to shower. The facility is Fire Cleared for four (4) bedridden clients. Three clients are bedridden/wheelchair and one client is ambulatory. LPA observed four bedrooms to have the appropriate bedding, nightstand and sufficient lighting for each client. In addition, LPA observed extra bedding and sheets in one of the restroom closets.
Laundry/Garage
LPA observed one of the laundry rooms located in the garage. The garage is not attached to the facility. The garage has incontinence supplies, extra hygiene and water supply enough for four clients. There is also extra wheelchairs and oxygen tanks in the garage. There is a sign for oxygen tank.

LIC 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: NATIONAL SUPPORT SERVICES HOME II
FACILITY NUMBER: 197608370
VISIT DATE: 11/29/2023
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Kitchen Area
LPA conducted a tour of the kitchen and observed there to be sufficient stock of perishables and non-perishable seven-day supply of foods in the refrigerator and enough for four clients. There are also several cabinets filled with extra can goods. LPA observed all knives/sharps and toxins locked in a cabinet located in one of the kitchen cabinets. The fire extinguisher is located in the kitchen and date 10/2023, fully charged. The first aid kit and manual are located in the kitchen area. The food menu and disaster plan are posted on the kitchen door. There is another washer/dryer located by the kitchen area. The medication is centrally stored and locked in this area.

The Living Room
Although there is three out of four clients bedridden there is enough seating for all clients including staff. The living room area has a tv, internet access and phone accessibility. There is no fireplace. There is proper lighting for the clients. The carbon monoxide and smoke detectors were tested and are functional. The room temperature reads at 73 Fahrenheit. Additionally, there is an signal alarm when any of the doors open.

The Dining Room
There is a dining room area that is located across from the kitchen where there is a table with proper seating for all four clients.

Physical environment
LPA toured the outside area of the facility where there is a shaded area for activities and big enough for wheelchair accessibility. There is enough seating for the three clients and staff. LPA observed appropriate outdoor furniture. No bodies of water on the premises. The backyard has one gate.

Administrative: The Annual fee is current. There is proper signs displaying and hygiene/covid procedures Rights of Individuals, If you see something say something, grievance, reporting complaints brochures against the wall by the dining room.

An exit interview was conducted, no citation issued, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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