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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609653
Report Date: 08/28/2024
Date Signed: 08/28/2024 03:26:46 PM

Document Has Been Signed on 08/28/2024 03:26 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:HERNAEZ RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197609653
ADMINISTRATOR/
DIRECTOR:		OSIO, JONAH REY G.FACILITY TYPE:
735
ADDRESS:11414 KELOWNA STTELEPHONE:
(747) 227-3450
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 5DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:26 PM
MET WITH:Leilani Osio - Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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A Required One (1) year visit was conducted today by Licensing Program Analysts (LPAs) Gary Tan, Angelica Segovia and Antonia Alvizar-Ettima. LPAs met with staff Leilani Osio. Purpose of visit was stated. This is a North Los Angeles Regional Center (NLARC) vendored facility level 3.

A tour of the physical plant was conducted at 12:45 PM and the following was noted:

The facility has a gate outside about 30 ft before getting into the main door. The only entrance being utilized is the main front door. 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 of Covid 19 prevention protocol signs were posted indoors. 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.

Facility has six (6) bedrooms and three (3) bathrooms. Three (3) bedrooms and two (2) bathrooms are designated for staff use. 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 112.5°F and within the required range.

(continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: HERNAEZ RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197609653
VISIT DATE: 08/28/2024
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(continued from LIC 809)

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.
Living, dining and family rooms 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 garage. Knives and sharps were kept in a locked drawer.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat was set 74.0°F and observed to be within the required range.
Fire extinguisher. There are two (2) fire extinguishers in the facility: one (1) in the kitchen and one (1) in the family room. Extinguishers were observed to be operable and last bought on 08/28/24. Smoke alarms are hardwired and interconnected. Carbon monoxide and smoke alarms were tested and observed to be operable.

The garage is currently being used as tools, supplies and used equipment storage and Laundry area. Laundry detergents and other cleaning agents and toxins are kept locked in the cabinet in the laundry area inside the garage. Medication was observed to be inaccessible and stored in a secured medication cabinet in the kitchen. There were two (2) complete First Aid kits in the medication cabinet.

Client records. All five (5) clients records were reviewed. Clients record appeared to be complete and current. Staff records were also reviewed. Four (4) staff records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 07/04/24. Required posting observed in facility (complaint hot line poster, personal rights, etc).



There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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