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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608555
Report Date: 04/12/2024
Date Signed: 04/12/2024 04:45:45 PM

Document Has Been Signed on 04/12/2024 04:45 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HOPKINS-SHIRLEY HOMEFACILITY NUMBER:
197608555
ADMINISTRATOR/
DIRECTOR:		TAMMY SHIRLEYFACILITY TYPE:
735
ADDRESS:9244 CREBS AVENUETELEPHONE:
(818) 701-6246
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 3DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:28 PM
MET WITH:Katheleen Hopkins- LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Licensee Katheleen Hopkins and explained the reason for the visit.
At approximately 12: 35 Pm, with the assistance of the Licensee, LPA took a tour of the physical plant. The smoke alarms are interconnected and battery-operated. There is a carbon monoxide detector that functions properly installed in the hallway between clients' rooms. The fire extinguisher is located in the kitchen. The purchase date is 5/8/23.
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 were stored in a locked cabinet in the kitchen. Properly labeled medications were locked in the kitchen cabinet. Required postings were observed in the kitchen. Bedrooms: The facility has five (5) bedrooms. Three (3) bedrooms are designated for clients' use and two (2) bedrooms are currently being used for staff. All three bedrooms, in use by clients, were properly furnished with appropriate bedding and linens with sufficient lighting.Bathrooms: The facility has three (3) bathrooms. There are two (2) bathrooms designated for clients' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 107.8 and 108.6 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: This includes the living room dining areas were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture
Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. No bodies of water on the premises.
Laundry Area-Garage: located through the kitchen. Appliances observed to be in good repair. Laundry detergents were locked in a cabinet and thus they were inaccessible to clients.
Temperature: Facility maintains a comfortable temperature of 77 degrees Fahrenheit.
(Continue on 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOPKINS-SHIRLEY HOME
FACILITY NUMBER: 197608555
VISIT DATE: 04/12/2024
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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.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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