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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609990
Report Date: 08/22/2024
Date Signed: 08/22/2024 11:00:11 PM


Document Has Been Signed on 08/22/2024 11:00 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:AMENA LOVE BOARD AND CAREFACILITY NUMBER:
197609990
ADMINISTRATOR:JONES, MERCERFACILITY TYPE:
740
ADDRESS:10751 VIKING AVETELEPHONE:
(747) 239-3247
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY:6CENSUS: 4DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mercer Jones- AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff Carlo Magcalas and explained the reason for the visit. Shortly after, LPA met with Administrator Mercer Jones. At approximately 9:40 am, with the assistance of staff, LPA took a tour of the physical plant, facility temp at 77 degrees. Required postings were observed in the entry area. The smoke alarms and carbon monoxide are properly functional. The fire extinguisher is located in the kitchen with date of purchase 08/22/2024.
Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets.
Bedrooms: The facility has five (5) bedrooms total. There were four(4) bedrooms designated for residents' use. One(1) bedroom is designated for staff. All bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting.
Bathrooms: There are five (5) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 110.2 degrees Fahrenheit.
Common Areas: These included the living room and dining area. The common areas were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Area: is located in the garage which is inaccessible to residents.
Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.
Medications: Medication and Medication Records were review for proper documentation.
Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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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