197608967-1-18-2024-31-AS-CALH-CZM3BQ-20240118170644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608967
Report Date: 01/18/2024
Date Signed: 01/18/2024 05:07:16 PM

Document Has Been Signed on 01/18/2024 05:07 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:	01/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Austin Shanks		TIME COMPLETED:	05:05 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

On 01/17/24 at around 09:30 AM Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – 1 Year Inspection and met with staff (S1) Administrator Austin Shanks who allowed LPA to enter. Facility is following COVID mitigation protocols, LPA’s temperature was taken upon entry. LPA explained the purpose of the visit and were accompanied by S1 inside and outside the facility during this inspection.

At 03:30 PM LPA Alemoh conducted a physical plant tour to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Facility temp measured at 72 degrees The facility consists of 3 client bedrooms, 1 staff bedroom, 2 bathrooms, a living room, dining room, laundry room and kitchen.

This facility is licensed to serve 4 adults ages 18 – 59 years. A total of 4 clients are currently residing in this facility, 4 out of 4 clients are non-ambulatory. A total of One (1) staff and four(4) residents and 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 a second half bathroom in the backyard equipped with functional toilet and sink designated for resident use.

Three 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.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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 2

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: 01/18/2024

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
26
27
28
29
30
31
32

Two (2) bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Alemoh tested hot water temperature and it measured between 113- and 114 degrees Fahrenheit. This facility provides clients with residents with hygiene products such as feminine napkins, non medicated 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 in Located in the rear pantry behind the kitchen. S1 does receive food donations from the Food Bank and disperses boxes of food as needed to residents. At the time of visit S1 has temporarily halted food bank delivery.

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 12/29/23. 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 Nov 16th, 2023.

At 04:00 PM LPA Alemoh conducted a file review.

Four (4) staff records were reviewed, 4 out of 4 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 Administrator Austin Shanks.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2