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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609741
Report Date: 07/22/2024
Date Signed: 07/22/2024 01:37:33 PM

Document Has Been Signed on 07/22/2024 01:37 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TRACY'S BOARDING CARE - HIAWATHAFACILITY NUMBER:
197609741
ADMINISTRATOR/
DIRECTOR:		JOY, ANCYFACILITY TYPE:
740
ADDRESS:17441 HIAWATHA STTELEPHONE:
(818) 455-2586
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 4DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Violeta TafatacTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 07/22/2024 at 9:35 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced, Annual Inspection and met with Violeta Tafatac, Administrator. LPA asked for the census, staff and resident files. The licensee arrived about fifteen (15) minutes later.

The physical plant was toured inside and out at 10:30 am.

Living/Dining Room Area: LPA Saucedo observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 75 degrees Fahrenheit with a large television. There is another refrigerator in the dining hall area. There is a fireplace that is covered.

Bedrooms: There are seven (7) bedrooms. Six (6) are used for residents and one (1) for a staff. In the hallway, there is a pantry filled with extra linen. LPA observed rooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the resident’s room. There are four (4) bedrooms that have a private bathroom.

Bathrooms: There are five (5) bathrooms that were toured and checked to make sure bathrooms were clean and in good repair. The hot water temperatures were measured within regulations of 115 degrees. The showers have non-slip bathmats and grab bars.

Medications were kept in a locked pantry at the entrance of the facility on your left-hand side. All medications were properly labeled and inaccessible to residents. The first aid kit and the files are kept also in this pantry.

LIC 809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRACY'S BOARDING CARE - HIAWATHA
FACILITY NUMBER: 197609741
VISIT DATE: 07/22/2024
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Kitchen Area: LPA inspected the kitchen area. There is one (1) refrigerator which was clean and in good operation in this area. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinets. The knives/sharps are in the kitchen on your right-hand side, inaccessible to the residents. The telephone line is on the counter. There is one (1) fire extinguisher fully charged and expires on May-2025.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has no body of water on the premises. There is one gate that is unlocked leading to the outside area towards the street.

The washer and dryer are located inside next to the kitchen area. The chemicals are in this area inaccessible to the residents.

The carbon monoxide and the smoke detector were tested, and they were operable, interconnected.

There is no garage but there is two locked doors and inaccessible to the residents. This area has extra wheelchairs, bedding for the residents.

There is a signal system for the facility.

Administration: The Liability Insurance was reviewed and will be renewed on 08/2024. There are several Covid 19 signs on the wall, hygiene sanitation signs, and the Ombudsman sign against the walls of the facility, YES, Emergency Disaster Plan, Theft and Loss Policy, Facility Sketch, and Personal Rights

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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