197610101-1-27-2023-31-AS-MCAA-CNGUYX-20230127150038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610101
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:00:43 PM

Document Has Been Signed on 01/27/2023 03:00 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:	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: 4	DATE:	01/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Rose Bigornia		TIME COMPLETED:	03:00 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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Rose Bigornia and explained the reason for the visit. At approximately 12:00pm, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired and interconnected. The smoke alarms is also interconnected with the carbon monoxide detector. The fire extinguisher is located in the hallway. The charge date is 11/6/2022. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There were four (4) bedrooms designated for residents' use. Two (2) bedrooms are shared and two (2) bedrooms are for private use. LPA observed the bedrooms, that are in use by residents to be properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 110 degrees Fahrenheit. LPA didn't observe any cleaning supplies or hazardous items being stored underneath the bathroom sink or accessible to the residents in care. Common Areas: These included the living room and dining area. The common areas were properly furnished. Furniture were observed to be in good repair and the floors were clean. Hallways and exits were free of obstruction. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: HAMLIN ELDER CARE	FACILITY NUMBER: 197610101
	VISIT DATE: 01/27/2023

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
26
27
28
29
30
31
32

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area, front and backyards were observed free of hazards.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications were stored and locked in a hallway closet. Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2