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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609816
Report Date: 02/25/2024
Date Signed: 02/25/2024 02:59:03 PM


Document Has Been Signed on 02/25/2024 02:59 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:STANSBURY PLACE INCFACILITY NUMBER:
197609816
ADMINISTRATOR:SHINN, MARIA ELENAFACILITY TYPE:
740
ADDRESS:8425 STANSBURY AVETELEPHONE:
(818) 924-7165
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:5CENSUS: 5DATE:
02/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Joshua Smith, LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 1:33 p.m., the LPA met with the Licensee, Joshua Smith and explained the reason for the visit. The facility is vendored by North Los Angeles Regional Center as a level three (3) home.

At 1:50 p.m., the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.
KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:15 p.m., hot water measured at 105.8-degree Fahrenheit. Medications are centrally stored and located inside a locked cabinet near the kitchen. The laundry units are located near the kitchen. The facility is a single-story residential home with five (5) bedrooms, four (4) for resident use and one (1) for staff use and two (2) bathrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 1:57 p.m., the hot water temperature tested at 108.4-degree Fahrenheit. OUTDOOR SPACE: The LPA observed the front and back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. There are no bodies of water on the premises. Hazardous items were inaccessible and locked away inside the locked outside sheds. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the fire extinguishers to be fully charged and last serviced on 07/01/2023. At 2:00 p.m., smoke alarms/ carbon monoxide detectors were tested and functioning properly. Starting at 2:06 p.m., the LPA conducted interviews with five residents (5) and one (1) staff.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2024
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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