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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610074
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:16:31 PM

Document Has Been Signed on 11/21/2024 01:16 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:VINTAGE HOME INC.FACILITY NUMBER:
197610074
ADMINISTRATOR/
DIRECTOR:
GALIZA, FILIPINASFACILITY TYPE:
735
ADDRESS:21048 VINTAGE STTELEPHONE:
(818) 700-9353
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 4CENSUS: 4DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Filipinas Galiza, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At 11:30am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Administrator and explained the reason for the visit.

Facility is licensed for capacity of four (4) Ambulatory clients. At 11:40am LPA toured the kitchen area and observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Laundry is located by the kitchen area and the washer/dryer appeared to be in good condition. All chemicals and detergents are kept locked in an attached garage and inaccessible to clients in care. At 11:50am, LPA observed all sharps locked under the sink and all medications were stored in a locked cabinet and inaccessible to clients in care. There are two (2) fire extinguishers located throughout the facility and were last serviced on 12/11/2023. Facility has nine (9) bedrooms of which four (4) bedrooms are designated for clients’ use. All bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap and paper towels. Extra towels and linens were readily available. The hot water temperature measured at 116.6°F. Facility maintains a temperature of 70°F. Smoke detectors and carbon monoxide monitors were tested at 12:05pm and observed to be functional. At 12:15pm, 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.

Between 12:30pm to 1:30pm, LPA reviewed records of four (4) client and two (2) staff. Client and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.

No deficiency cited during today's visit.
Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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