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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610107
Report Date: 07/13/2021
Date Signed: 07/13/2021 02:00:17 PM

Document Has Been Signed on 07/13/2021 02:00 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:YOSEMITE CARE HOMEFACILITY NUMBER:
197610107
ADMINISTRATOR:BOOTH, EVANGELINEFACILITY TYPE:
740
ADDRESS:1465 YOSEMITE DR.TELEPHONE:
(626) 399-7755
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY: 6CENSUS: 0DATE:
07/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Evangeline BoothTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Angela Panushkina, Patrick Shanahan and Melissa Ruiz conducted an announced Pre-Licensing visit to this facility. LPAs met with an applicant Evangelina Booth (Licensee/ Administrator).

Around 12:10pm, LPA conducted a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a 3 bedrooms, 2 and 1/2 bathrooms, single story family residence that includes a living room, dining area, kitchen and attached garage.

Bedrooms: The facility has 3 resident bedrooms that was fire cleared as of 02/14/21 for (4) non - ambulatory elderly residents and (2) bedridden resident located in room # 1 & 2. Bedrooms were checked and had all the required linens, furniture and lighting. There is an extra supply of linens and hygiene products. There is a caregiver room for live in staff. A Dementia program and bedridden addendum was also submitted. While touring room 3, it appears that there was some unlicensed construction that shortened room three in order to make a room for staff. The emergency exit lead to another unlicensed patio construction were there were tools, chemicals, paints and ladders accessible. Another unlicensed bathroom was observed in the patio area.

Bathrooms: Bathrooms were clean and only one bathroom had the required grab bars and non slip rugs. There is soap, towels and toilet paper stocked in the garage. Toilet(s) have commode chairs with hand rails, Water temperature measured at 109.8 degrees Fahrenheit. The resident bathroom had also been altered without permits and no longer had a wooden door but an accordion style door that would limit residents privacy.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
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: YOSEMITE CARE HOME
FACILITY NUMBER: 197610107
VISIT DATE: 07/13/2021
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Kitchen: Was clean and stocked with perishable and non perishable foods. There is an extra refrigerator in the garage which is also stocked with food. Sharp kitchen knives is stored in a locked drawer located in the kitchen. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. All chemicals, toxins, and laundry supplies are stored in a locked cabinet located in the kitchen area and is inaccessible to the residents. Common areas and grounds: The washer and dryer is located in the garage inaccessible to residents. Medications are locked in the dining room cabinet along with the residents files. The back yard has a covered patio area and a table with umbrella and seating for clients room. The floor of the patio was rotten and weak when LPA’s stepped on it. Tools and chemicals were accessible through out the patio. There is a locked storage section in the backyard but is only able to lock on one side and is accessible from room #3. There are no cameras in place at this time. There is an auditory monitor for each exit. All smoke detectors were checked and operating. Smoke detectors are hardwired and located throughout the facility. Carbon Monoxide detectors were located throughout. The carbon monoxide detector is placed in the common living room which is also the activity room. The following items are needed for the facility to comply with Title 22:

1. Permit for bedroom #3, staff room and a resident bathroom

2. Permits for side and a back patio

3. Outdoor fencing for the backyard

4. Storage area is accessible through room #3 and can only be locked from one side.

5. None of the exits to the outdoor has ramps

1. Stove on a side patio needs to be removed

2. The deck on a side patio is in a poor/rotten condition and needs to be replaced to accommodate functional outdoor space for the residents

This report will be sent to the Centralized Application Bureau (CAB).

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
LIC809 (FAS) - (06/04)
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