197608977-8-30-2022-31-AS-NRED-CHSU6B-20220830151804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608977
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:18:12 PM

Document Has Been Signed on 08/30/2022 03:18 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:	THOMPSON'S GUEST HOME		FACILITY NUMBER:	197608977
ADMINISTRATOR:	SAVELLA, JEFFREY		FACILITY TYPE:	740
ADDRESS:	22835 STRATHERN ST		TELEPHONE:	(818) 348-0995
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY:	6	CENSUS: 6	DATE:	08/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Ronald Mendoza		TIME COMPLETED:	03:38 PM

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At 2:20 p.m. on 08/30/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

The facility was last visited on 05/21/2022 for an annual visit. It is a single story building with 5 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden in Bedroom #3. The facility serves residents with dementia. Approved hospice waivers for 6.

LPA observed a maintained front yard. Signs were posted at the front for the facility’s masking policy and other COVID precautions. Once inside, LPA observed postings for the facility license, administrator certificate, resident rights, resident councils, family councils, facility sketch, ombudsman contacts, confidential complaint contacts, emergency contacts, activity schedule, menu, and house rules. LPA was screened for infectious disease upon entry. The screening station contained hand sanitizer, digital thermometer, and visitor log. The visitor log tracked temperature, symptoms, and vaccination status. Staff noted that the facility was undergoing renovations. No immediate health or safety concerns were observed, and all hazardous items were locked.

The facility has 5 bedrooms. Bedroom #1 and Bedroom #2 are private. Bedroom #3 and Bedroom #4 are shared. Bedroom #5 is designated for staff. The staff bedroom was unlocked and free of hazards. Residents in Bedroom #4 were in bed and reported enjoying the facility. Bedroom #3 had a motion sensing pad near one of the beds. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. 4 out of 4 auditory alarms were on and functioning. Exit doors were unlocked and free of obstructions. The facility has 4 bathrooms. The shared bedrooms each have a private bathroom. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: THOMPSON'S GUEST HOME	FACILITY NUMBER: 197608977
	VISIT DATE: 08/30/2022

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Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. A closet in the hallway contained an adequate supply of fresh linens. At approximately 2:35 p.m. LPA measured the room temperature to be 72 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable food in the kitchen. The appliances were sanitary and in good condition. Sharps and cleaning solutions were locked below the sink and counter. The laundry area near the kitchen contained an operable washer and dryer. Medications were locked near the kitchen. The facility has a separate locked refrigerator for cold medications. The front patio and back yard were shaded and contained furniture in good condition. The garage was ajar, and all hazards were locked in a cabinet. At approximately 2:50 p.m. staff tested the dual functioning smoke and carbon monoxide detector in the living room to be operational. Detectors are hardwired, and 3 out of 3 detectors functioned simultaneously. At 2:55 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 03/22/2022.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report, appeal rights, and citation(s) issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC809 (FAS) - (06/04)

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