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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608513
Report Date: 03/08/2022
Date Signed: 03/08/2022 12:29:31 PM

Document Has Been Signed on 03/08/2022 12:29 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:SMITH ADULT HOMEFACILITY NUMBER:
197608513
ADMINISTRATOR:PAULA SMITHFACILITY TYPE:
735
ADDRESS:8921 DEBRA AVENUETELEPHONE:
(818) 894-5685
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 5CENSUS: 3DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mary LarezTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Pitz conducted an unannounced infection control visit on this day.

LPA was greeted upon entry and screened for COVID-19 symptoms by staff. LPA toured the facility with staff and confirmed that they do have an approved mitigation plan on file. LPA utilized the infection control domain of the ARF inspection tool to verify that the facility was in compliance with various aspects of the mitigation plan, including but not limited to: screening visitors, having ample handwashing/ sanitizing supplies on site, having adequate PPE on site, having signs posted throughout the facility to remind residents and staff of various Covid precautions.

LPA did not note any concerns at the time of visit.

Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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