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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609725
Report Date: 09/18/2023
Date Signed: 09/18/2023 12:01:40 PM

Document Has Been Signed on 09/18/2023 12:01 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:IVANA MASON HOME INCFACILITY NUMBER:
197609725
ADMINISTRATOR:LIEM, INGEFACILITY TYPE:
735
ADDRESS:7638 MASON AVETELEPHONE:
(818) 648-8118
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 4CENSUS: 4DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Inge LiemTIME COMPLETED:
12:00 PM
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At 9:30 a.m. on 09/18/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the Licensee and disclosed the reason for the visit. LPA and Licensee toured the facility inside and out at 10:00 a.m. today. No immediate health and safety risks were observed.

The facility was last visited on 08/11/2022 for an annual visit. It is a single story building with 5 bedrooms, 2 bathrooms, kitchen. garage, common areas, and outdoor areas. It has an approved fire clearance for 4 ambulatory clients. A file review was completed prior to the visit.

Entry: The yard at the main entrance was well maintained. Once inside, LPA observed hand sanitizer and masks.

Bedrooms: The facility had 5 bedrooms. 3 bedrooms served as client bedrooms, and one bedroom was used as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

Bathrooms: The facility had 2 bathrooms. Bathrooms contained liquid soap, paper towels, and a trash can with a tight fitting lid. At approximately 11:15 a.m. LPA measured the water temperature to be 108.4 degrees Fahrenheit.

Common areas: Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:15 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit. LPA observed a functioning house phone in the living room. A fire place was turned off and appropriately covered.

Kitchen: LPA observed an adequate supply of perishable and non-perishable foods. The stove hood was clean. Appliances were in good condition. Sharps and mediations were locked above the counter top.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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: IVANA MASON HOME INC
FACILITY NUMBER: 197609725
VISIT DATE: 09/18/2023
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Laundry: A washing machine and dryer were located near the kitchen. Both were in working order. Detergents and cleaning solutions were locked above the appliances.

Outdoor areas: LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. A small pool was locked and inaccessible. A fireplace was appropriately grated.

Safety: All emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. At approximately 10:20 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 10:25 a.m. LPA observed a fully charged fire extinguisher in the hallway.

Garage: The garage was locked and inaccessible. It contained an additional refrigerator and freezer and extra supplies.

At 11:30 a.m. LPA reviewed staff and resident files.

During today's inspection, the facility was in compliance with Title 22 regulations.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC809 (FAS) - (06/04)
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