197609303-12-22-2022-31-AS-JGTN-CHVU7M-20220902152010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609303
Report Date: 09/02/2022
Date Signed: 12/22/2022 04:10:57 PM

Document Has Been Signed on 12/22/2022 04:10 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:	TWIN OAKS GUEST HOME LLC		FACILITY NUMBER:	197609303
ADMINISTRATOR:	AKAHOSHI, TAMI		FACILITY TYPE:	740
ADDRESS:	3246 HONOLULU AVE		TELEPHONE:	(818) 249-3107
CITY:	LA CRESCENTA	STATE: CA	ZIP CODE:	91214
CAPACITY:	6	CENSUS: 6	DATE:	09/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	Tami Akahoshi - Administrator		TIME COMPLETED:	03:30 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	Licensing Program Analyst (LPA) Gary Tan, met with administrator Tami Akahoshi for a One (1) Year Required Infection control visit for this facility. A tour of the physical plant was conducted at 1:15 PM and the following were noted: The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear mask and must be screened. Screening area is located around 10' upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened by the staff upon entry. All staff were observed to be wearing mask. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted on the walls. 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 seven (7) bedrooms and four (4) bathrooms currently occupying six (6) residents on six (6) private bedrooms. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents and has hospice waiver for two (2). (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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: TWIN OAKS GUEST HOME LLC	FACILITY NUMBER: 197609303
	VISIT DATE: 09/02/2022

NARRATIVE

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Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:

Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguisher was filled and last checked on 03/31/22. There is carbon monoxide detector installed at the facility.

The front porch of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility.

The garage is detached from home and currently being used as frozen foods, tools, supplies, cleaning solutions and other toxins storage.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Dishwashing liquid and laundry detergents are kept at a locked cabinet near the laundry area. The laundry area is located adjacent to the kitchen. Knives and sharps are observed to be also kept in the locked.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Staff rooms are locked. No medications are observed in the staff room.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range 105.3°F to 108.9°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. First aid kit is observed to be with complete tools and supplies.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

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