197609340-9-20-2022-31-AS-MCAA-CJFTAR-20220920143358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609340
Report Date: 09/20/2022
Date Signed: 09/20/2022 02:34:05 PM

Document Has Been Signed on 09/20/2022 02:34 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:	JACKIE'S HIDEAWAY A		FACILITY NUMBER:	197609340
ADMINISTRATOR:	TAL, TALY		FACILITY TYPE:	740
ADDRESS:	5925 DONNA AVE		TELEPHONE:	(818) 345-6752
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 6	DATE:	09/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Margarita Piza		TIME COMPLETED:	02:45 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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Margarita Piza and explained the reason for the visit. At 11:50am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are battery operated. There is a carbon monoxide detector near the kitchen that functions properly. There are two fire extinguishers located near the kitchen and at the entrance of the facility. The charge date is 7/27/2022. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled prescribed and PRN medications were locked in the kitchen cabinets. Bedrooms: There are six (6) bedrooms designated for residents' use. All six rooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are five (5) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 109.4 and 120 degrees Fahrenheit. No cleaning supplies, toxins or chemicals were stored in resident bathrooms during inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Although not in use, the fireplace was properly screened with no key present to ignite. Also, no tools for the fireplace were in sight or accessible to residents in care

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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: JACKIE'S HIDEAWAY A	FACILITY NUMBER: 197609340
	VISIT DATE: 09/20/2022

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. There is no swimming pool or bodies of water. The outdoor area was free of hazards. The laundry room is located by the kitchen. No cleaning supplies and detergent were observed or accessible to the residents. The laundry room is inaccessible to residents. Adjacent to the laundry room is staff office that is also inaccessible to residents.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted. A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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