197610103-3-5-2025-31-AS-PKHN-DEGT5M-20250305132546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610103
Report Date: 03/05/2025
Date Signed: 03/05/2025 01:27:03 PM

Document Has Been Signed on 03/05/2025 01:27 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	INGOMAR HOME		FACILITY NUMBER:	197610103
ADMINISTRATOR/ DIRECTOR:	SOSKIN, MICHAEL		FACILITY TYPE:	735
ADDRESS:	21007 INGOMAR ST		TELEPHONE:	(323) 854-7740
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY: 4		CENSUS: 4	DATE:	03/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Millicent Dimson - House manager		TIME VISIT/ INSPECTION COMPLETED:	01:35 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

On 3/5/2025 at 9:30am Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival LPA was greeted by the Caregiver/DSP Lucia Patao who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. LPA Khurshudyan reviewed the required postings on a walls throughout the facility. The House Manager arrived at approximately 11:00am.
The inspection tool was used to complete today's visit.

At 10:15am. LPA with the help of the caregiver began a physical plant tour of the facility and the following was observed: This is a single-story building with four (04) bedrooms, two and half (2.5) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for four (4) clients. Facility is operating level 4G clients.

Kitchen: LPA observed a seven-day supply of non-perishable food and a two-day supply of perishable food properly stored and labeled. Facility stores knives and sharps inside kitchen cabinet that is always locked and under supervision. Emergency supply of food / water was stored inside the pantry. LPA observed fully charged one (1) fire extinguisher located in the kitchen by the refrigerator. Fire extinguisher service date is 01/24/2025. A weekly menu was also available.

Common Areas: These include living and dining areas. LPA observed dining, living areas clean and clear of clutter. Furniture is generally new and in a good repair. Dining and living room furniture sits the capacity of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:00am. LPA measured the room temperature to be 72 degrees Fahrenheit. There is a linen closet in the hallway with an adequate supply of fresh linens ready to use. No obstructions and or tripping hazards throughout the facility. Facility has landline, LPA checked it was operational.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: INGOMAR HOME	FACILITY NUMBER: 197610103
	VISIT DATE: 03/05/2025

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

LPA observed a fireplace in the living room nicely gated with plants and got informed that the fireplace is non operational. There is a television and various activities, games, board games, art supply available for clients to use.

Bedrooms: There are four (4) bedrooms in the facility, of which three (3) are designated for clients use and one (1) for staff use. One bedroom is shared by two (2) clients. LPA observed bedrooms to be properly furnished with beds, linens, night stands, chairs, drawers, closets, and adequate lighting. All bedrooms appeared organized and clean.

Bathroom: There are two and a half (2.5) bathrooms in the facility. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. Hot water temperature was taken in both bathrooms at approximately 11:10am measured 109.4 degrees Fahrenheit. LPA also observed required signs on the bathroom walls and non-skid mats inside the showers.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by a staff at 12:25pm and were observed operational.

Garage: LPA observed the garage is attached to the facility and has access from the kitchen/sitting area and is currently being used as a storage for PPE supplies and for other tools.

Laundry Room: Functioning washer and dryer located in a separate locked area next to the kitchen. Disinfectants, laundry detergents and hygiene supplies were stored and inaccessible in a separate locked cabinet.

Backyard: LPA observed sufficient yard space and fenced backyard. Appropriate outdoor furniture, with covered shaded area available for clients to rest and enjoy the outside weather. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. The facility does not have a swimming pool or body of water.

Staff/Client File review: Facility records are kept inside locked commercial cabinets next to the office area. At 11:10am-12:20pm. LPA conducted records review of six (6) staff files and four (4) out four (4) clients records. Files were complete and updated.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: INGOMAR HOME	FACILITY NUMBER: 197610103
	VISIT DATE: 03/05/2025

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

Medications: At approximately 12:45pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). LPA observed centrally stored medication, and First Aid kit locked in the commercial cabinet and inaccessible to clients in care. LPA observed First-aid kit is complete and has new manual. PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. Facility operates with two (2) shifts and has two or three staff members for each shift.

An emergency exit plan/sketch is posted on the wall along with other posting requirements.

LPAs collected LIC500, LIC9020 and Administrators certificate.

No deficiency cited on today’s visit. Exit interview conducted. Copy of this report provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3