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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609881
Report Date: 12/10/2024
Date Signed: 12/10/2024 02:44:40 PM

Document Has Been Signed on 12/10/2024 02:44 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:HAI-YEN HOME CAREFACILITY NUMBER:
197609881
ADMINISTRATOR/
DIRECTOR:		NGUYEN, YENFACILITY TYPE:
735
ADDRESS:21720 VINTAGE STREETTELEPHONE:
(818) 818-6211
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 4CENSUS: 4DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Roldan Tungol, Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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At 12:40 PM, Licensing Program Analyst (LPA), Huma Rahimi, 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:

Kitchen: At approximately, 12:55 PM, 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 01/02/24.

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. A separate room is designated for live-in staff and LPA observed locked and inaccessible to clients in care.

Bathrooms: At 1:00 pm 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 110.8°F.

Common Areas: The facility maintains a comfortable temperature at 69°F. The living room and dining area 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.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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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: HAI-YEN HOME CARE
FACILITY NUMBER: 197609881
VISIT DATE: 12/10/2024
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Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:10 PM they were tested and observed to be operational.

Outside areas: At approximately, 1:15 PM 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 at the facility.



Medications: At approximately, 1:20 PM, LPA observed medications are centrally stored and locked in the kitchen cabinet.

Between 1:30 PM to 2:30 PM, LPA reviewed records of four (4) clients and two (2) staff. Clients and staff records appeared to be complete and updated.

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: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
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