197608905-9-10-2024-31-AS-JGTN-D8YUT7-20240910155127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608905
Report Date: 09/10/2024
Date Signed: 09/10/2024 03:51:56 PM

Document Has Been Signed on 09/10/2024 03:51 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MY HOME II		FACILITY NUMBER:	197608905
ADMINISTRATOR:	MARK YULE		FACILITY TYPE:	740
ADDRESS:	6753 ESTEPA DRIVE		TELEPHONE:	(661) 219-4906
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	6	CENSUS: 4	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:17 PM
MET WITH:	Mark Yule - Administrator		TIME COMPLETED:	04:00 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 Analysts (LPAs) Gary Tan, initially met with staff Josephine Pataueg for a One (1) Year Required visit for this facility. Staff called the administrator Mark Yule who arrived 10 minutes later. LPAs explained the reason for the visit. There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation plan. Signs of Covid 19 prevention protocol signs were posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the side yard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with the administrator at 1:30 PM. The facility is a single storey building with six (6) residents' bedrooms and two (2) bathrooms currently occupying four (4) residents. There is an additional bedroom and bathroom designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents. Hospice waiver for one (1) resident. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with dining The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguishers were observed to be filled and last bought on 10/22/23. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MY HOME II	FACILITY NUMBER: 197608905
	VISIT DATE: 09/10/2024

NARRATIVE

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The side yard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. The swimming pool is appropriately fenced and was observed to be locked during visit. There is no garage at the facility only driveway at the front. There is a shed at the side yard being used as a storage for old equipment and other supplies. The laundry area is located inside the staff bathroom and observed to be locked and inaccessible to the residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies including detergents and pesticides and other toxins are stored in the cabinet under the sink. Knives and sharps are observed to be kept in a locked drawer in the kitchen.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 108.0°F to 111.5°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed the medication cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aid kit has complete tools and supplies.

Client records: Client records are reviewed. Client records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff record. Staff records appeared to be complete and updated.

Disaster drill was last conducted on 06/19/2023. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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