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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608555
Report Date: 03/08/2022
Date Signed: 03/08/2022 01:58:19 PM

Document Has Been Signed on 03/08/2022 01:58 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:HOPKINS-SHIRLEY HOMEFACILITY NUMBER:
197608555
ADMINISTRATOR:TAMMY SHIRLEYFACILITY TYPE:
735
ADDRESS:9244 CREBS AVENUETELEPHONE:
(818) 701-6246
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 3DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Kathleen Hopkins, Licensee TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Licensee Kathleen Hopkins for an unannounced one (1) year Required visit for this facility. LPA arrived at 12:25 pm and was greeted by the Licensee. LPA informed the Licensee of the purpose of the visit.

Infection control: LPA reviewed the facility mitigation plan (approved on 03/11/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened, and sanitizer was available upon entry.

A tour of the physical plant was conducted with the Licensee at 12:32 pm. The facility has five (5) bedrooms and three (3) bathrooms currently occupying three (3) clients. Two (2) bedrooms and one (1) bathroom are currently being used for staff rooms and storage for PPE Supplies. The facility is Fire Cleared for four (4) ambulatory clients.

Food Inspection
LPA conducted a tour of the kitchen around 12:32 pm and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and medications locked in the cabinet.

Living and dining
At 12:34 pm, LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 68°F. The smoke detectors were tested and observed to be operational at 12:50 pm. The Licensee informed the LPA that the carbon monoxide detector is not currently working. The Licensee stated the Fire Marshal visited the facility on 3/4/22 and gave the facility two weeks to provide a receipt for the purchase of a new carbon monoxide detector. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 11/04/21.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
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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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: HOPKINS-SHIRLEY HOME
FACILITY NUMBER: 197608555
VISIT DATE: 03/08/2022
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Resident Rooms
At 12:36 pm, LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client. LPA observed extra bedding and sheets in the hallway closet.

Physical environment
LPA toured the outside area of the facility at 12:40 pm. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Bathrooms
At 12:45 pm LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs will be posted in the bathroom. Hot water was tested at 1:15 pm and measured within regulation at 116.7 degrees F

Laundry/Garage
At 1:30 pm, LPA observed the laundry room located in the garage. The Garage is attached to the facility and currently being used for extra storage. LPA observed chemicals/hazardous items in a locked cabinet.


Administrative: LPA collected the client roster and the LIC.500. Annual fee is current.


An exit interview was conducted, citation issued, and a copy of this report was given to the Licensee.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/08/2022 01:58 PM - It Cannot Be Edited


Created By: Shira Stamps On 03/08/2022 at 01:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOPKINS-SHIRLEY HOME
FACILITY NUMBER: 197608555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
§1503.2 Carbon monoxide detectors required; inspection. Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on statement form the Licensee, the Licensee did not comply with the section cited above in that the Licenee did not have a functioning carbon monoxide detector which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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The Licensee agrees to replace the carbon monoxide detector and submit a receipt to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


LIC809 (FAS) - (06/04)
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