197608967-11-20-2023-31-AS-CALH-CXS3MH-20231120172221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608967
Report Date: 11/06/2023
Date Signed: 11/20/2023 05:23:06 PM

Document Has Been Signed on 11/20/2023 05:23 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:	SHANKS BOARD & CARE		FACILITY NUMBER:	197608967
ADMINISTRATOR:	AUSTIN SHANKS SR.		FACILITY TYPE:	735
ADDRESS:	13055 WEIDNER STREET		TELEPHONE:	(818) 896-9304
CITY:	PACOIMA	STATE: CA	ZIP CODE:	91331
CAPACITY: 6		CENSUS: 5	DATE:	11/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Austin Shanks		TIME COMPLETED:	02:30 PM

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On 11/6/23 at around 9:25 AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – 1 Year Inspection at Shanks Board and Care and met with staff (S1) Administrator Austin Shanks and (S2) Assistant Administrator Rita Bell. LPA explained the purpose of the visit and were accompanied by S1 and S2 inside and outside the facility during this inspection.

Facility temp measured at 79 degrees The facility consists of 3 client bedrooms, 1 staff bedroom, 1 bathroom, a living room, dining room, laundry room and kitchen.

This facility is licensed to serve 6 adults ages 18 – 59 years. A total of 5 clients are currently residing in this facility, 5 out of 5 clients are ambulatory. A total of 2 staff and no clients were present during this inspection.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. Facility has backyard half bathroom for residents. Facet temperature read at 119 degrees.

3 out of 3 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Alemoh tested hot water temperature in the middle hallway client restroom, and it measured between 114- and 115.1-degrees Fahrenheit. This facility provides clients with residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Located in the rear pantry behind the kitchen. S1 receives food donations from the Food Bank and disperses boxes of food as needed to residents.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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: SHANKS BOARD & CARE	FACILITY NUMBER: 197608967
	VISIT DATE: 11/06/2023

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LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. All Medication and knives are stored in a cabinet adjacent to the kitchen. Documents are posted as mandated. Last Disaster drill was conducted on 10/29/23. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors are hardwired and in compliance and operational. Two (2) Fire Extinguishers were observed throughout the facility purchase date is April 24^{th, 2023}. Kitchen fire extinguisher purchase date is.

Five (5) staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Five (5) client records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. LPA Alemoh reviewed P&I money, 5 out of 5 residents P&I were intact and were not commingled with facility funds or petty cash. All client/resident and staff files are locked in small rolling cabinet in the dining room inaccessible to residents.

No deficiencies cited

An exit interview was conducted. A copy of this report and appeal rights were discussed and left with Assistant Administrator Rita Bell.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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