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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610101
Report Date:
01/11/2021
Date Signed:
01/11/2021 11:52:23 AM
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:
HAMLIN ELDER CARE
FACILITY NUMBER:
197610101
ADMINISTRATOR:
BIGORNIA, LIMA ROSE
FACILITY TYPE:
740
ADDRESS:
20300 HAMLIN ST.
TELEPHONE:
(818) 912-6289
CITY:
WINNETKA
STATE:
CA
ZIP CODE:
91306
CAPACITY:
6
CENSUS:
0
DATE:
01/11/2021
TYPE OF VISIT:
Prelicensing
UNANNOUNCED
TIME BEGAN:
11:00 AM
MET WITH:
Lima Rose Bigornia
TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) conducted a pre-licensing visit virtually through Face-Time with applicant Lima Rose Bigornia.
LPA was given a tour of the physical plant of the facility. Facility is fire cleared for a capacity of six with five non ambulatory and one bedridden. LPA observed bedroom #1 to be a shared room with a private bathroom. LPA observed it to be appropriately furnished. The bathroom had grab bars and non skid material. Bedroom #2 is a private room that was observed to be appropriately furnished. Bedroom # 3 is fire cleared for bedridden resident. It is a shared room which was appropriately furnished. Bedroom #4 is a private room which was observed to be appropriately furnished. LPA was given a tour of the living room of the facility. LPA observed it to be furnished and in good order. LPA observed appropriate signs and posters on the wall. LPA was given a tour of the kitchen. LPA observed facility to have a sufficient amount of perishable and non perishable food. LPA observed knives and sharp objects to be locked away and inaccessible. LPA observed the refrigerator to be in good condition. LPA observed a washer and dryer off to the side of the kitchen.
LPA observed the backyard of the facility to be free of clutter and debris. LPA checked the garage and found it to be used for storage at this time.
No deficiencies cited during this visit. LPA will forward report to Central Application Unit. Exit Interview conducted. Copy of report will be emailed to applicant for signature.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
01/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/11/2021
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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