197609881-1-20-2022-31-AS-APAA-CAUT8H-20220120133021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609881
Report Date: 01/20/2022
Date Signed: 01/20/2022 01:32:16 PM

Document Has Been Signed on 01/20/2022 01:32 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HAI-YEN HOME CARE		FACILITY NUMBER:	197609881
ADMINISTRATOR:	NGUYEN, YEN		FACILITY TYPE:	735
ADDRESS:	21720 VINTAGE STREET		TELEPHONE:	(818) 818-6211
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY: 4		CENSUS: 4	DATE:	01/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Yen Nguyen, Administrator		TIME COMPLETED:	01:50 PM

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At 12:15pm Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Administrator, Yen Nguyen, who granted access to the facility. LPA explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

Infection control: Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for clients and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: At approximately, 12:25pm LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a drawer and inaccessible to clients in care. Fire extinguisher in the kitchen was purchased on 01/20/22.

Bedrooms: There are four (4) bedrooms designated for clients use with sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens.

Bathrooms: At 12:40pm LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Hot water temperature measured at 110.7°F.

Common Areas: The facility maintains a comfortable temperature at 68°F. The living room and dining area

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAI-YEN HOME CARE	FACILITY NUMBER: 197609881
	VISIT DATE: 01/20/2022

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appeared clean and were properly furnished. The living room has a television, comfortable furniture and the fireplace is adequately screened. No obstructions and or tripping hazards throughout the facility. Laundry is located by the office/staff room. LPA observed all detergents locked and inaccessible to clients in care. Extra PPE supplies and food storage was also observed.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 12:48pm they were tested and observed to be operational.

Outside areas: At approximately, 12:50pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

Medications: At approximately, 12:30pm LPA observed medications are centrally stored and locked in the kitchen cabinet.

Administrative: LPA collected Certificate of Liability Insurance, and LIC.500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC809 (FAS) - (06/04)

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