197609704-10-16-2023-31-AS-TSMH-CWNTZS-20231016151048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609704
Report Date: 10/16/2023
Date Signed: 10/16/2023 03:10:52 PM

Document Has Been Signed on 10/16/2023 03:10 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:	SAFE LAUREL LLC		FACILITY NUMBER:	197609704
ADMINISTRATOR:	GBOYEGA AKINBOLA		FACILITY TYPE:	735
ADDRESS:	16300 VINTAGE ST		TELEPHONE:	(818) 489-1218
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 3	DATE:	10/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Cheryl Perkins		TIME COMPLETED:	03:16 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), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 11:25 am. LPA disclosed to the administrator the purpose of the visit. LPA conducted a tour of the physical plant at approximately 11:30 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the loving/dining room combination, and kitchen. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be clean, sanitary and have adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the four (4) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen foods. Food pantry in kitchen stocked with can goods and boxed foods. Resident medications and sharps are stored in lower kitchen cabinets next to stove. Medications and sharps observed to be locked and inaccessible to residents in care. Two (2) new first aid kits stored in large cabinet in living room. Toxins are stored and locked under kitchen sink and observed to be locked an inaccessible to residents. There are two (2) fire extinguishers in facility attached to the wall: One (1) in entry hallway and one (1) in kitchen; both observed to be charged. Laundry room is located in alcove at back of kitchen. The appliances observed to be functional. The locked cabinets above washer and dryer contain laundry detergents and supplies. (Cont. to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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: SAFE LAUREL LLC	FACILITY NUMBER: 197609704
	VISIT DATE: 10/16/2023

NARRATIVE

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(Cont. from 809)

The facility has a total of four (4) bedrooms and three (3) bathrooms for residents in care. Staff office through kitchen.

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 111.2, 114.1. and 119.0 -degrees Fahrenheit.

Backyard has the following: Covered patio with two (2) tables and chairs. Patio furniture observed to be in good repair with adequate seating for residents.

Attached Garage but no indoor access: Additional refrigerator, PPEs and storage.

Smoke detector/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards.

At approximately 12:10 pm, LPA reviewed three (3) resident files. Resident files included current Individual program plans (IPP), Individual services plans (ISP). Four (4) random staff files reviewed. Staff files had the appropriate trainings to include CPI, First aid and CPR.

Exit Interview Conducted /Copy of the Report Issued

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC809 (FAS) - (06/04)

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