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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609591
Report Date: 12/16/2023
Date Signed: 12/16/2023 11:58:46 AM

Document Has Been Signed on 12/16/2023 11:58 AM - 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:T R E HOME IFACILITY NUMBER:
197609591
ADMINISTRATOR:JAMES CALHOUNFACILITY TYPE:
735
ADDRESS:1315 NORTON AVENUETELEPHONE:
(310) 863-4952
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY: 5CENSUS: 4DATE:
12/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Olushola EbunTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with caregiver, Olushola Ebun, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 8:00 AM and the following was noted:

There is one entrance being utilized at the facility. The facility has a total of five (05) bedrooms and four (04) bathrooms. The facility is fire cleared for three (03) non-ambulatory. The facility is currently occupying four (04) non-ambulatory residents.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a swimming pool/body of water with required gate and lock. The garage is currently being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away.

Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. Living and dining room furniture were also checked.

The living and dining room are neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the family room, observed to be full and last inspected on 09/20/23.

(continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2023
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: T R E HOME I
FACILITY NUMBER: 197609591
VISIT DATE: 12/16/2023
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The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 117.9°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

LPA observed medication and first aid kit to be locked and inaccessible to residents.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023
LIC809 (FAS) - (06/04)
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