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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609674
Report Date: 05/07/2023
Date Signed: 05/16/2023 10:56:50 AM

Document Has Been Signed on 05/16/2023 10:56 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VERBENA CTFACILITY NUMBER:
197609674
ADMINISTRATOR:TINDLE, TRACEYFACILITY TYPE:
735
ADDRESS:37318 VERBENA CTTELEPHONE:
(661) 305-4744
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
05/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Tracy Tindle - AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced One (1) Year Required visit to this facility. LPA met with administrator Tracy Tindle and explained the purpose of the visit. This facility is North Los Angeles Regional Center Vendored facility level 4I.

A tour of the physical plant was conducted at 9:15 AM and the following was noted:

The front main door is the only entrance being utilized at the facility. There is a sign on the front door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

The facility had submitted approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. 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 back yard. The facility has sufficient stock of PPE in stock..

Facility has (3) client bedrooms: one (1) shared and two (2) private room; facility has three (2) bathrooms. One (1) bathroom is designated for staff use. There is no body of water in the facility.

Bedrooms were toured and observed to be clean and appropriately furnished. There are sufficient supplies of linen and towels in the linen cabinet.

(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2023
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: VERBENA CT
FACILITY NUMBER: 197609674
VISIT DATE: 05/07/2023
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Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.

Bathrooms were observed to be clean and with necessary supplies. Hot water temperature measured at 112.8°F. Laundry room is located going through the garage, laundry detergents and other cleaning agents are kept in the cabinet in the laundry room. Laundry room was observed to be locked during visit.

Living and dining room 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 disinfectants, cleaning solutions and toxins are locked in the cabinet in the laundry room. Knives and sharps were observed to be locked in the kitchen cabinet. Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 75°F and observed to be within the required range.

Fire extinguisher was located in the dining area. Fire extinguisher was observed to be full and last inspected on 02/15/23. Dual smoke/carbon monoxide alarms are hardwired and interconnected. Alarms were tested and observed to be operable. There is a pull system in the house.

Garage is attached to the house but no access from the inside. Garage is currently being used as frozen food, toxins and other supplies storage. The garage is also being used as an informal office of the administrator. The garage was observed to be locked and inaccessible to residents.

Medications were observed to be locked, inaccessible and stored in locked filing cabinet. There is a complete first aid kit located in the medication cabinet. Client records were also reviewed. Client records appeared to be complete and updated. Staff records were also reviewed. Staff has criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate observed to be current.

Disaster drill was last conducted on 04/26/23. Required posting observed in facility (complaint hot line poster, personal rights, etc).

Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2023
LIC809 (FAS) - (06/04)
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