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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608993
Report Date: 06/21/2024
Date Signed: 06/21/2024 12:49:01 PM


Document Has Been Signed on 06/21/2024 12:49 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:LIVING GRACEFUL RCFEFACILITY NUMBER:
197608993
ADMINISTRATOR:GLADYS MANIAGOFACILITY TYPE:
740
ADDRESS:10651 DESPLAIN PLACETELEPHONE:
(818) 468-7200
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 6DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sinagtala Limbo, House Manager/DesigneeTIME COMPLETED:
01:15 PM
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At 11:15am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Designee who granted access to the facility. Administrator was contacted and LPA explained the reason for the visit.

At 11:20am LPA conducted a tour of the physical plant and observed the following:
Facility has five (5) bedrooms designated for resident’s use, three (3) bathrooms and one staff room (room #6). Facility is licensed for capacity of six (6) of which six (6) non-ambulatory and six (6) bedridden residents. It has also been approved for a hospice waiver for six (6) residents. LPA was able to tour the home and did not observe any immediate health and safety concerns. Facility maintains a temperature of 77°F. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The fire extinguisher was observed in the kitchen and the living room area and was last serviced on 12/22/23. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. The hot water temperature measured at 107.5°F. Extra towels and linens were readily available. Laundry area is located in the garage and LPA observed all chemicals and detergents are kept locked and inaccessible to residents. At 12:00pm, smoke detectors and carbon monoxide monitors were tested and observed to be functional. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Between 12:15pm to 12:50pm, LPA reviewed records of six (6) residents and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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