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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609892
Report Date: 11/05/2021
Date Signed: 11/05/2021 10:36:08 AM

Document Has Been Signed on 11/05/2021 10:36 AM - 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:BEWISE HOME COVELLOFACILITY NUMBER:
197609892
ADMINISTRATOR:OKONKWO, CHINWEIKEFACILITY TYPE:
735
ADDRESS:20616 COVELLO STREETTELEPHONE:
(818) 300-4994
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 4CENSUS: 4DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ana Rojas/ AdminTIME COMPLETED:
10:53 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct a required annual visit and infection control visit. Upon entry, LPA's temperature was taken and COVID 19 questions were asked before being allowed entry.

LPA was able to tour the home and inspect the home for health and safety concerns. The facility has 4 rooms for residents and 1 room for staff. There are also 2 restrooms available for residents use. The fire extinguisher was last replaced on 2/11/21. The smoke alarms were tested and functioned properly. A carbon monoxide detector was observed in the hallway and appeared functional.

No health and safety concerns were observed during today's visit. The facility is following their approved mitigation plan.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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