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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609756
Report Date: 08/19/2023
Date Signed: 08/19/2023 12:30:02 PM

Document Has Been Signed on 08/19/2023 12:30 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:COMPASSION HOMEFACILITY NUMBER:
197609756
ADMINISTRATOR:NUSIFA BAHINGIREFACILITY TYPE:
735
ADDRESS:17726 COMMUNITY STTELEPHONE:
(818) 324-9589
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 4CENSUS: 4DATE:
08/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Farumah Nassanga - LicenseeTIME COMPLETED:
12:00 PM
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A One (1) year Required visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with the licensee Fatumah Nassanga and purpose of visit was stated. This facility is a North Los Angeles Regional vendored facility Level IV-G.

At 8:43 AM, A tour of the physical plant was conducted with Ms. Nassanga and the following was noted:

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

The facility had submitted and approved Mitigation and Infection plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted on the walls. 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.

Facility has four (4) client bedrooms and one and a half (1 1/2) bathrooms. There is a section in the house dedicated for staff use. There are three (3) staff bedroom, a bathroom and a small kitchen inside the section. The staff section was observed to locked during visit. There is no body water in the facility.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have sufficient supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at a range of 109.1°F to 109.5°F and within the required range. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMPASSION HOME
FACILITY NUMBER: 197609756
VISIT DATE: 08/19/2023
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's 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 the toxins, cleaning solutions and disinfectants are locked in the cabinet on the bedroom hallway. Knives and sharps were also stored in a locked cabinet in the kitchen and inaccessible to residents. Laundry area is located adjacent to the kitchen going to the staff section. Laundry soap and other cleaning agents are stored in a locked cabinet in the laundry area.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat was set at 76.0°F and observed to be within the required range.
Fire extinguisher. The fire extinguisher is located in the kitchen and observed to be operable and last serviced on 05/04/23. Smoke alarms are hardwired and interconnected. Alarms were tested and observed to be operable. There were dual carbon monoxide detector/smoke alarm installed in the facility. Garage is detached to the house and currently being used as used equipment storage and was observed to be locked. There is also a structure in the backyard being used as storage. Client records were reviewed for current IPP and/or Needs and Services plans, physician report and admission agreements. Client records appeared to be complete and current.

Medication was observed to be inaccessible and stored in a secured cabinet. There is a complete First Aid kit in the medication cabinet.


Staff records were checked. Staff present has criminal record clearances and associated to this facility.
Staff records appear to be complete and current.
Disaster drill was last conducted on 08/16/23. Required posting are observed to be complete and current and displayed properly at the facility.

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2023
LIC809 (FAS) - (06/04)
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