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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609591
Report Date: 02/24/2025
Date Signed: 02/24/2025 03:42:17 PM

Document Has Been Signed on 02/24/2025 03:42 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:T R E HOME IFACILITY NUMBER:
197609591
ADMINISTRATOR/
DIRECTOR:		JAMES CALHOUNFACILITY TYPE:
735
ADDRESS:1315 NORTON AVENUETELEPHONE:
(310) 863-4952
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY: 5CENSUS: 4DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:DSP, King TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection to the facility. LPA met with Direct Support Professional (DSP) and granted entry to the facility. At 10:00a.m. DSP called Administrator and indicated that will not be able to join todays visit. Administrator authorized Assistant Administrator to sign the report and the purpose of this visit was explained. Later, Assistant Administrator joined the visit.

At 10:15a.m., DSP and LPA conducted physical plant tour inside and out. During the tour, LPA observed that the facility has five(05) private bedrooms and three (03) bathrooms. Fire drill was last conducted on 11/13/2024. Required posting observed in facility (complaint hot line poster, personal rights, etc).

The front main door is the only entrance being utilized at the facility. The facility had submitted and approved Mitigation and Infection Plan. Hand washing signs were posted in the bathrooms. All trash cans were observed to be with cover.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Bedrooms were toured and observed to be clean and properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Linen storage was also checked and observed to have ample supply of clean linen.
Bathrooms were observed to be clean, sanitary and with necessary supplies. The appropriate grab bars and mats in the shower. Hot water temperature measured at a range of 113.7°F to 115.5°F and within the required range. Client’s personal hygiene supplied are kept in their personal space. Towels and washcloths are not shared.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: T R E HOME I
FACILITY NUMBER: 197609591
VISIT DATE: 02/24/2025
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(continued from LIC 809)
Common Areas: These included the living room, dining room and family area for clients. The common areas were properly furnished. Furniture in common area was observed to be in good repair. Fireplace was closed, blocked-off and non-operational. Clients dining table fits five (05) clients. Office space is adjacent to dining area which is designated for staff use maintains staff folder and office supplies.
Kitchen Area is observed to be clean and sanitary. All disinfectants, cleaning solutions and other toxins were observed to be locked in the closet next to front entry door and inaccessible to clients in care.
Food: LPA observed at least two (02) days perishable and seven (07) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Food storage and preparation areas are clean and inaccessible to pests. Temperature of facility wall thermostat was set at 72.0°Fahrenheit and observed to be within the required range. Fire extinguishers were observed to be located thru the facility. Fire extinguishers were observed to be operable with purchased receipt dated of 09/25/2024. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational.
Medication were observed to be locked, inaccessible and stored in the cabinet in the office space. There were several complete first aid kits located inside the front entry closet.
Surrounding Grounds The front grounds of the facility are well landscaped. No obstractions and or tripping hazards throughout the facility. The facility has a swimming pool/body of water with required gate and lock. The garage is currently being used for extra perishable, non-perishable food, storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away front entry closet.
Client records. All four (04) client records were reviewed. Clients record are complete and current at this time. Staff records were also reviewed complete and current at this time. Staff have current first aid and training documentation showing training completed. Administrator's certificate was observed to be current.

No health and safety hazards noted during the visit. A citation was issued and appeals rights were provided and a copy of this report was given to Assistant Administrator.

Exit interview conducted.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2025 03:42 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 02/24/2025 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: T R E HOME I
FACILITY NUMBER: 197609591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(19)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above the kitchen sink is falling, garbage disposal not working and plumbing is leaking for a couple weeks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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Licensee will fix the sink, plumbing, and garbage disposal by POC due. Licensee will submit a picture to CCL by POC due dated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
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