197610098-3-9-2023-31-AS-JGTN-CPRVGK-20230309152540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610098
Report Date: 02/11/2021
Date Signed: 03/09/2023 03:26:00 PM

Document Has Been Signed on 03/09/2023 03:26 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:	AFFORDABLE BOARD AND CARE INC.		FACILITY NUMBER:	197610098
ADMINISTRATOR:	KESHISHI, VILBERT		FACILITY TYPE:	740
ADDRESS:	11382 KAMLOOPS ST		TELEPHONE:	(818) 397-5690
CITY:	LAKEVIEW TERRACE	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 0	DATE:	02/11/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Vilbert Keshishi - Licensee Representative		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Gary Tan conducted an announced virtual Pre Licensing tele visit to this facility and met with applicant representative Vilbert Keshishi. The applicant is "Affordable Board and Care Inc". Fire Clearance dated 11/14/2020 was received for six (6) non-ambulatory residents, one (1) of which may be bedridden on room #1 Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following: The facility dual smoke/carbon monoxide alarm system is hard wired and interconnected. The fire extinguisher is located in the kitchen and was observed to be fully charged and last bought on 05/30/2020. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested and observed to be operational. Hot water was tested in the common bathrooms and measured at a range from 112.5°F to 113.5°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are four (4) resident bedrooms, two (2) private and (2) shared bedrooms. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records will be stored in a locked filing cabinet in the kitchen area. Medications will also be stored in the same locked cabinet. The first aid kit is readily available. There are two (2) bathrooms in the facility. The common bathroom has non-skid mat and appropriate grab bars installed. (continued on LIC 809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AFFORDABLE BOARD AND CARE INC.	FACILITY NUMBER: 197610098
	VISIT DATE: 02/11/2021

NARRATIVE

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(continued from LIC 809)

The kitchen knives are stored in a locked cabinet in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the garage. The laundry area is located in the garage, the garage was observed to be locked. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. There is no garage at the facility, only driveway. There is no body of water in the facility.

Component III was conducted to the administrator

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

A telephonic exit interview was conducted with Licensee Representative Vilbert Keshishi and a copy of the report was provided via email for signature.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC809 (FAS) - (06/04)

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