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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609293
Report Date: 09/10/2023
Date Signed: 09/10/2023 04:26:19 PM

Document Has Been Signed on 09/10/2023 04:26 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:16TH STREET HOME CARE INCFACILITY NUMBER:
197609293
ADMINISTRATOR:MACIAS, OSCARFACILITY TYPE:
735
ADDRESS:44920 16TH STREET WESTTELEPHONE:
(661) 373-3223
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4; 4CENSUS: 3DATE:
09/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Carmen Dacanay - StaffTIME COMPLETED:
04:30 PM
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A Required Annual visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Carmen Dacanay who called the administrator Annie Calderon and designated her to sign the report. Purpose of visit was stated. This is a North Los Angeles Regional Center vendored facility level 2.

At 1:45 PM, A tour of the physical plant was assessed and the following was noted:

The only entrance being utilized is the main front door, there is a sign at the main door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the front and backyard. The facility has sufficient stock of PPE in the storage room.

The facility has four (4) private client bedrooms and two (2) bathrooms. There is one (1) additional bedroom designated for staff use and another room used as an office. There is no body of water in the facility.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 111.5°F and within the required range..
Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2023
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: 16TH STREET HOME CARE INC
FACILITY NUMBER: 197609293
VISIT DATE: 09/10/2023
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(continued from LIC 809)

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet along the bedroom hallway.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is set at 70°F and observed to be within the required range.
Fire extinguisher There is a fire extinguisher located in the kitchen. Extinguisher was observed to be full and last bought on 10/12/22. Dual smoke alarms/carbon monoxide are tested and observed to be operable.

Garage is converted into an activity area for the clients. The garage is also use for storage of frozen foods, emergency food supplies and PPE.



Client records. All three (3) clients record were reviewed for current IPP and/or Needs and Service plans. physician report, admission agreements and P & I funds. Client records appeared to be complete and current.

Medication was observed to be inaccessible and stored in a secured cabinet located near the dining room. Medication records and procedures reviewed with staff. There is a complete First Aid kit located in the kitchen.

Staff records were reviewed. Staff has criminal record clearances and associated to this facility. Staff records appear to be complete and current.

Disaster drill was last conducted on 06/19/23. Required posting are observed to be complete and current and displayed properly at the facility.

There is no health and safety issue during this visit. Exit interview conducted. Copy of this report issued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2023
LIC809 (FAS) - (06/04)
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