197608513-4-17-2023-31-AS-TSMH-CQYS33-20230417133029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608513
Report Date: 04/17/2023
Date Signed: 04/17/2023 01:30:59 PM

Document Has Been Signed on 04/17/2023 01:30 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 HOME		FACILITY NUMBER:	197608513
ADMINISTRATOR:	PAULA SMITH		FACILITY TYPE:	735
ADDRESS:	8921 DEBRA AVENUE		TELEPHONE:	(818) 894-5685
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 5		CENSUS: 3	DATE:	04/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Paula Smith		TIME COMPLETED:	01:40 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	At 9:40 am Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by administrator and disclosed the purpose of the visit. LPA conducted a tour of the physical plant at approximately 9:50 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the kitchen, living room/dining combination, family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the three (3) residents currently residing there. Two (2) days of perishable food 7 days non-perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps and first aid are stored in locked living room closet. The resident medications are stored and locked in living room/hall closet. Sharps and medications observed to be inaccessible to residents. There are five (5) fire extinguishers: one behind main entry door, one in hall closet attached to wall, one in living room, one in kitchen, and in in linen cabinet in hallway. Laundry room is located off the kitchen. The appliances observed to be functional. Toxins stored above in locked living room/hall closets observed to be locked and inaccessible to residents. ( Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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

FACILITY NAME: SMITH ADULT HOME	FACILITY NUMBER: 197608513
	VISIT DATE: 04/17/2023

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
26
27
28
29
30
31
32

( Cont from 809)

The facility has a total of five (5) bedrooms and three (3) bathrooms: Three (3) bedrooms and two (2) bathrooms are for residents; two (2) bedrooms and one (1) bathroom for staff. The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 124.5 and 123.7 degrees Fahrenheit.

Backyard has the following: 1 covered patio area and two (2) uncovered patio areas. All areas have table/chairs with sufficient seating for the residents. Patio furniture observed to be in good repair

Detached Garage: Used for extra food/water/PPEs.
No body of water at the facility.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 11:30 am , LPA reviewed files for the three (3) residing residents. Resident files included medical assessments and individual personal plans. Staff files reviewed for all three (3) staff. Staff files had First aid/AED/CPR, medication training's and appropriate DSP training's.

No deficiencies cited

Exit Interview Conducted / A Copy of the Report Issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2