197608511-11-16-2023-31-AS-MCAA-CXMU5F-20231116141640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608511
Report Date: 11/16/2023
Date Signed: 11/16/2023 02:17:33 PM

Document Has Been Signed on 11/16/2023 02:17 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CASA BLANCA HOMECARE		FACILITY NUMBER:	197608511
ADMINISTRATOR:	MARILOU A. ANDREAS		FACILITY TYPE:	740
ADDRESS:	17216 GOYA STREET		TELEPHONE:	(818) 366-2234
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	4	CENSUS: 2	DATE:	11/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Marilou Andreas		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Marilou Andreas and explained the reason for the visit. At 10:15am, with the assistance of the administrator, LPA took a tour of the physical plant. The facility is a two story building, but only the first floor is licensed for operation. Only the licensee/owner occupies the second floor. No residents are allowed on the second floor. Required postings were observed in the entry area. The smoke alarms are hardwired and interconnected. The carbon monoxide detector is located in the dining room area. The fire extinguisher is located in the kitchen. It was purchased on 11/30/22. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and cleaning supplies are being stored in locked drawers. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There are three (3) bedrooms designated for residents' use. Two (2) bedrooms are for private use, and one (1) is shared. Bedrooms in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There is one (1) bathroom designated for the residents' use, which was observed to be properly supplied and had functional fixtures. Hot water temperature was measured at 110.5 degrees Fahrenheit. There were no cleaning supplies stored in the bathroom during the day's inspection. Common Areas: These included the living room and dining area, which is next to each other. The common areas were properly furnished with a dining room table, large enough to seat six (6). The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA BLANCA HOMECARE	FACILITY NUMBER: 197608511
	VISIT DATE: 11/16/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. There is a swimming pool, which is properly fenced with a five foot gate enclosing it. There is a lock at the gate, making entry inaccessible for the residents to gain entry without supervision. The garage is designated for extra storage and the laundry area. There is also an additional refrigerator for extra perishable food storage. PPE and cleaning supplies are maintained in the garage. Entry to the garage from the inside of the home is locked at all times, and requires a combination to unlock and gain entry.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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