197608768-9-20-2024-31-AS-LNCA-D9AU5G-20240920151643

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608768
Report Date: 09/19/2024
Date Signed: 09/20/2024 03:16:51 PM

Document Has Been Signed on 09/20/2024 03:16 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:	DEARBORN HOME		FACILITY NUMBER:	197608768
ADMINISTRATOR/ DIRECTOR:	LORA MAY TEMPORAL PANA		FACILITY TYPE:	735
ADDRESS:	16513 DEARBORN STREET		TELEPHONE:	(626) 926-7186
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 4	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:56 AM
MET WITH:	Lucky Pana- Asst. Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 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) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff Joan Cuayzon met and explained the reason for the visit. At 12:15 PM Lucky Pana arrived who is the assistant administrator met with LPA and was explained the reason for the visit as well. At 12:00 NN, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 10/11/2023. During the visit the facility is at 74 degrees Fahrenheit. The facility is fire cleared for four (04) bedridden residents and is approved for two (2) hospice waiver. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet under the kitchen sink. The menu was posted for review (ARF), snacks and beverages are available for the resident in the facility when they want. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen cabinet below the sink. Bedrooms: There were four (4) bedrooms designated for client's use. Room #1, bedroom #2 and bedroom #3 and bedroom #4 are all for private used.. The bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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

FACILITY NAME: DEARBORN HOME	FACILITY NUMBER: 197608768
	VISIT DATE: 09/19/2024

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Bathrooms: There are two (2) bathroom designated for clients' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.4 degrees Fahrenheit for bathroom #1 located in the hallway beside bedroom #2. Bathroom #2 is beside the kitchen. Hot water temperature was measured at 107.4 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for four (4). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The garage detached and is used for storage.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked storage in the laundry area and is located in the living room by the entrance.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the dining area. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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: DEARBORN HOME	FACILITY NUMBER: 197608768
	VISIT DATE: 09/19/2024

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Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current IPP’s and surety bonds (LIC 402) a copy was handed to LPA. Planned activities are offered. LPA reviewed four (4) of the four (4) clients funds and observed receipts and funds balanced.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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