197608555-11-27-2023-31-AS-GSAO-CXYTU9-20231127140158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608555
Report Date: 11/27/2023
Date Signed: 11/27/2023 02:02:21 PM

Document Has Been Signed on 11/27/2023 02:02 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:	HOPKINS-SHIRLEY HOME		FACILITY NUMBER:	197608555
ADMINISTRATOR:	TAMMY SHIRLEY		FACILITY TYPE:	735
ADDRESS:	9244 CREBS AVENUE		TELEPHONE:	(818) 701-6246
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 4		CENSUS: 3	DATE:	11/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Kathleen Hopkins		TIME COMPLETED:	02:00 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) Gina Saucedo and Licensing Program Manager Troy Agard met with Licensee Kathleen Hopkins for an unannounced one (1) year required visit for this facility. LPA arrived at 10:10 am at the facility but there was no answer. A phone all was made to contact the licensee and was greeted by the Licensee Kathleen Hopkins about thirty (30) minutes after. LPA and LPM informed the Licensee the purpose of the visit. Infection control: LPA reviewed the facility mitigation plan that had previously been submitted to the Licensing office. A Copy of the Infection Control has been sent to the office. A tour of the physical plant was conducted with the Licensee at 10:51am. Resident Rooms 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. The client rooms are single housed. One of the bedrooms has a private bathroom. The bathroom temperature is 118.8 Fahrenheit and has non-skid mats. The facility is Fire Cleared for four (4) ambulatory clients. There are currently only three clients being housed. LPA and LPM observed rooms to have the appropriate bedding, nightstand and sufficient lighting for each client. In addition, LPA and LPM observed extra bedding and sheets in the hallway closet. LIC 809-C Continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOPKINS-SHIRLEY HOME	FACILITY NUMBER: 197608555
	VISIT DATE: 11/27/2023

NARRATIVE

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Food Inspection
LPA and LPM 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. There is an extra freezer in the kitchen, where extra frozen foods are stored. There are also several cabinets filled with extra can goods. LPA and LPM observed all knives/sharps and medications locked in the cabinet located in one of the kitchen cabinets. In addition, there are two fire extinguishers. One dated 05/2022 and one dated 05/2023. The first aid kit and manual are located in the kitchen area. The food menu is located on the refrigerator door.

The Living Room
The living room has plenty of seating for the clients with a tv and internet access. There is also a telephone line that works attached to a fax machine. There Is a fireplace that has a protected covering. The fireplace is capped off and is not usable. There is proper lighting for the clients. The carbon monoxide and smoke detectors were tested and are functional. The room temperature reads at 69 Fahrenheit.

Physical environment
LPA and LPM toured the outside area of the facility where there is a shaded area for activities. There is enough seating for the three clients and staff. LPA and LPM observed appropriate outdoor furniture. No bodies of water on the premises. There are three gates located in the backyard. The backyard has a fenced area.

Laundry/Garage
LPA and LPM observed the laundry room located in the garage. The garage is attached to the facility via the kitchen area and is currently being used for extra storage such as extra hygiene supplies. The toxins are in the garage area in a cabinet locked and secured.

Administrative: LPA had the LIC 500 and Infection Control emailed to her. The Annual fee is current. The Disaster plan is located against the wall in the kitchen/living room area and hygiene/covid, proper signage on the walls leading to the garage area and in the bathrooms. The last fire drill was 09/2023.

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

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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