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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610097
Report Date: 05/11/2024
Date Signed: 05/11/2024 11:35:12 AM

Document Has Been Signed on 05/11/2024 11:35 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SACRED HEART HOME CARE, LLCFACILITY NUMBER:
197610097
ADMINISTRATOR/
DIRECTOR:
BUGAY, CONSTANCIA R.FACILITY TYPE:
735
ADDRESS:28277 FOXLANE DRIVETELEPHONE:
(661) 210-8274
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91351
CAPACITY: 4CENSUS: 1DATE:
05/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ricardo Bugay & Constancia BugayTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Tuesday Cabiness conducted an unannounced annual required visit. LPA was greeted by staff Ricardo Bugay, and allowed LPA to enter. He was informed the reason of the visit. Administrator Constancia Bugay was contacted and arrived later during the visit.

LPA conducted a tour of the physical plant at to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the clients needs. These included the living/dining/ kitchen and client rooms; including bathrooms. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be clean, and comfortable for client's needs.

Kitchen: LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the four (1) client currently residing in the home. The freezer is stocked with meats and frozen foods; with an extra refrigerator located in the garage. Food pantry in kitchen stocked with can goods and boxed foods. Client medications and sharps are stored in kitchen cabinets. First aid kits was inspected. Toxins are stored and locked under kitchen sink and laundry room, and locked an inaccessible to clients. Bedrooms: The facility has (6) bedrooms residents; with (2) rooms for staff. Client rooms have appropriate lighting, furniture, bedding, and linens. There are sufficient linens observed and available. Bathrooms: There are (3); all were clean, with soap and towels. Hot water was checked. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. Fire extinguisher fully charged. First aid kit furnished fully equipped.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2024
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: SACRED HEART HOME CARE, LLC
FACILITY NUMBER: 197610097
VISIT DATE: 05/11/2024
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Smoke alarms and carbon monoxide detectors are functioning. The facility has a sufficient supply of PPE supply. Record review: A complete record review of staff and clients were conducted; all required documents were in files. There were no medication errors. All staff are vaccinated; including the (1) client.

No citation issued; exit interview and copy of report provided.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2024
LIC809 (FAS) - (06/04)
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