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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608977
Report Date: 08/30/2024
Date Signed: 08/30/2024 02:44:48 PM

Document Has Been Signed on 08/30/2024 02:44 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:THOMPSON'S GUEST HOMEFACILITY NUMBER:
197608977
ADMINISTRATOR/
DIRECTOR:
SAVELLA, JEFFREYFACILITY TYPE:
740
ADDRESS:22835 STRATHERN STTELEPHONE:
(818) 348-0995
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY: 6CENSUS: 6DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Iyen Madi-CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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An unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan on 8/30/24 at 10:00 am. Upon arrival LPA met with facility staff Iyan Medi, who granted access to the facility. LPA explained the reason for the visit. Shortly after the facility Administrator Jeffrey Savella arrived and helped with physical plant tour and provided staff/residents files.

During today's visit, LPA conducted a physical plant walk through, at approximately 10:40am, to ensure that
the facility is in compliance with rules and regulations under California Code of Regulations, Title 22.
The following was observed:

Facility is licensed for capacity of six (6) residents, of which six (6) may be Non-Ambulatory and one (1) bedridden. The facility has hospice waiver for six (6) residents. LPA observed all required postings were on the wall. This is a single-story house with five (5) bedrooms, of which 4 bedrooms are designated for residents’ use. Bedroom #1 and Bedroom #2 are private. Bedroom #3 and Bedroom #4 are shared have their own bathroom. Bedroom #5 is designated for staff. LPA observed staff bedroom was free of hazards. Bedrooms are appropriately furnished and have appropriate lighting. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 10:55 to be 111°F. Extra towels and linens were readily available. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. The facility has alarms on all exit doors, LPA observed alarms are operational. Centrally stored medications are locked in the cabinets located in the kitchen area. PRN medications have written orders from a physician. The facility serves residents with dementia and staff meets the needs of residents with dementia. Potentially dangerous items are kept inaccessible to residents with dementia. There is staff to meet Facility has 2 staff for AM shift and 1 awake caregiver for PM shift. No immediate health or safety concerns were observed.

Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: THOMPSON'S GUEST HOME
FACILITY NUMBER: 197608977
VISIT DATE: 08/30/2024
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LPA observed the kitchen area, there was sufficient stock of one week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. LPA observed that sharp objects were stored in a locked drawer inaccessible to residents in care. The kitchen has a working gas stove, microwave, refrigerator, and freezer. Extra emergency food was properly stored inside the storage cabinet. The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 11:00am to be 75°F. No obstructions and or tripping hazards throughout the facility found.
The Facility has one (1) fire extinguishers, LPA observed it was last purchased on 02/02/2024. Laundry
machines are located in the kitchen area. LPA observed all chemicals and detergents are kept locked and
inaccessible to residents in care. Kitchen chemicals are locked under the sink, and other chemicals are locked in the garage. Smoke detectors and carbon monoxide monitors were tested at 1:30pm and observed to be functional. LPA observed a clean and comfortable covered patio and backyard furniture to accommodate the six (6) residents. Exit doors were unlocked and free of obstructions. LPA checked inside of the locked shed it was used for facility tools and maintenance purposes. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. The facility does not have a swimming pool or body of water. The garage is used for extra storage and had cabinets stored with emergency food.
Between 11:45am to 2:30pm, LPA reviewed records and files of six (6) residents and three (3)
staff/caregivers. A review of staff and resident records appeared to be complete. Resident’s files contain a
signed admission agreements and a medical assessment, and all other required documentarians. A review of
staff records indicates that all facility staff and who required caregiver background checks have received
criminal record clearances. There are no residents with prohibited conditions residing at the facility.
At approximately 1:35pm to 2:00pm LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. All medications are properly labeled and checked for expiration dates. The facility has a separate locked refrigerator for cold medications.
First-aid has all proper items and is current.
LPA collected LIC500, LIC9020, Copy of the Liability Insurance and the Infection Control.
Facility is in compliance with Title 22 Regulations at this time. No citations issued during this visit.

Exit interview conducted and copy of this report signed and delivered to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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