<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608967
Report Date: 02/24/2022
Date Signed: 02/24/2022 05:55:56 PM

Document Has Been Signed on 02/24/2022 05:55 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SHANKS BOARD & CAREFACILITY NUMBER:
197608967
ADMINISTRATOR:AUSTIN SHANKS SR.FACILITY TYPE:
735
ADDRESS:13055 WEIDNER STREETTELEPHONE:
(818) 896-9304
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY: 6CENSUS: 6DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Austin Shanks TIME COMPLETED:
04:20 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) Tihesha “Lynn” Smith made an unannounced annual required visit at 11:55 am. Upon entry LPA explained the purpose of the visit to House Manager: Rita Bell. The administrator was called and arrived later.

LPA Smith conducted a physical plant tour of the facility. All smoke alarms/carbon monoxide detectors were working properly.

The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and detergents were stored and locked in storage room near kitchen. Properly labeled medications were locked in a cabinet near the kitchen.
The common areas appeared clean and properly furnished.
There were three (3) bedrooms designated for residents' use. All bedrooms were furnished and had sufficient lighting.
There was one (1) bathroom designated for residents' use. The bathroom was properly furnished. The hot water temperature was checked and found to be 105.8 degrees F.
The outdoor area was clean and free of hazards.

At approximately 1:45 pm LPA conducted a review of client, staff, and medication records. No deficiencies cited. Exit interview conducted/Report emailed
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1