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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609725
Report Date: 08/11/2022
Date Signed: 08/15/2022 08:01:49 AM

Document Has Been Signed on 08/15/2022 08:01 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
CCLD Regional Office, 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: 6CENSUS: 5DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Wijono SusiloTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Wijono Susilo and explained the reason for the visit.

At 9:15am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected an the carbon monoxide detector is functional, located in the hallway between client rooms. The fire extinguisher is also located in the hallway. The charge date is 8/12/2022. Wijono was reminded date is almost due. He noted and scheduled for renewal.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets.

Bedrooms: There were five (5) bedrooms. Three (3) are designated for residents' use. Three of the bedrooms, in use by residents were were properly furnished with appropriate beddings and linens with sufficient lighting. The other two bedrooms are for staff use.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 110 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were properly furnished and kept clean. In door temperature was maintained at 80 degrees.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVANA MASON HOME INC
FACILITY NUMBER: 197609725
VISIT DATE: 08/11/2022
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. There is a jacuzzi that was observed with a fence all around, covered and locked. The outdoor area was free of hazards. The laundry area and detergents are located by the kitchen.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 of the CA Code of Regulations, no deficiencies observed during the visit.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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