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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610057
Report Date: 10/05/2024
Date Signed: 10/05/2024 02:57:24 PM

Document Has Been Signed on 10/05/2024 02:57 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MAHONIA AVEFACILITY NUMBER:
197610057
ADMINISTRATOR/
DIRECTOR:		TINDLE, TRACEYFACILITY TYPE:
735
ADDRESS:37206 MAHONIA AVETELEPHONE:
(661) 305-4744
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 0DATE:
10/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Tracy Tindle - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Tracy Tindle and explained the reason for the visit. This will be a North Los Angeles Regional Center (NLARC) vendored facility Level IV-I, application is still pending with NLARC at this time.

LPA conducted physical plant tour inside and out at 1:12 PM. During the tour, LPA observed that the facility has four (4) bedrooms and two (2) bathrooms. There is no body of water in the facility.

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the back yard. The facility has sufficient stock of PPE in the storage

Bedrooms were toured and observed to be clean and appropriately furnished.

Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 109.4°F to 117.6°F.

(continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MAHONIA AVE
FACILITY NUMBER: 197610057
VISIT DATE: 10/05/2024
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions and laundry detergents were observed to be locked in the laundry room.
Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguisher was observed to be located by the kitchen. Extinguisher was observed to be operable and last inspected on 08/05/24. Dual Fire alarms/carbon monoxide are hardwired and interconnected, tested and observed to be operational.
Medication cabinet was observed to be locked in a filing cabinet located in the living room. There was a complete first aid kit located in the medication cabinet. Knives and sharps are also locked and secured in a tool box inside the locked storage room adjacent to the dining area.
Garage is attached to the house and observed to be locked and inaccessible to clients. Garage is also used as frozen food, emergency supplies, tools and old equipment storage. Laundry room is located in a room leading to the backyard.

Client records. No client at this time.

There was no health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2024
LIC809 (FAS) - (06/04)
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