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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608768
Report Date: 11/30/2022
Date Signed: 11/30/2022 11:39:58 AM

Document Has Been Signed on 11/30/2022 11:39 AM - 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:DEARBORN HOMEFACILITY NUMBER:
197608768
ADMINISTRATOR:LORA MAY TEMPORAL PANAFACILITY TYPE:
735
ADDRESS:16513 DEARBORN STREETTELEPHONE:
(626) 926-7186
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lora May Temporal Pana TIME COMPLETED:
11:40 AM
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On 11/30/22 Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection. Upon arrival LPA was greeted by the Administrator. The purpose of the visit was explained. LPA conducted a physical plant tour, and the following was observed: Infection Control: Administrator and staff were observed to be wearing surgical masks. LPA was designated to sign in the visitor’s log and LPAs temperature was taken. Covid-19 infection control signage were observed outside of the facility. Infection control signage was also observed inside in the common areas, hallways, and bathrooms. Facility has sufficient PPE supplies for more than 30 days. A fire extinguisher was observed and has a date of service of 8/11/2022. Smoke detectors and carbon monoxide and dual functioning and are hardwired throughout the facility. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked cabinet along with chemicals and cleaning supplies. Common Areas: All common areas were observed to be clean and properly furnished. Facility’s temperature at the time of the visit was 73 F. Client Rooms: Four (4) bedrooms are for client use, all of which were toured and appear to be clean and properly furnished. All rooms have adequate lighting and furniture. Bathrooms: There are two (2) bathrooms in the facility. LPA observed all bathrooms to be cleaned, paper towels available and trash cans with tight fitting lids. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water on the ground. A fire extinguisher was observed and has a date of service of 8/11/2022. Smoke detectors and carbon monoxide and dual functioning and are hardwired throughout the facility. LPA spoke to the Administrator about reporting requirements regarding covid clients and staff. No deficiencies cited. Report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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