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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610112
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:06:13 PM

Document Has Been Signed on 12/07/2023 03:06 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CREBS COMPASSION HOMEFACILITY NUMBER:
197610112
ADMINISTRATOR:MOSES T BAHINGIREFACILITY TYPE:
735
ADDRESS:9343 BALCOM AVETELEPHONE:
(818) 324-9589
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 4; 4CENSUS: 4DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Moses Bahingire- AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with the House Manager Alex Guilsi and Administrator Moses Bahingire has joined shortly after. At approximately 10:20 am, with the assistance of staff, LPA took a tour of the physical plant. The smoke alarms and carbon monoxide are functional. The fire extinguisher is located in the kitchen. The charge date is May 4, 2023. This is a 6-bedroom, 5- bathroom two story adult residential facility. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. LPA found a kitchen knife in one of the kitchen drawers that was unlocked. Staff immediately took the knife and stored it away. Properly labeled medications were locked in the entry closet. Bedrooms: There were four (4) bedrooms designated for clients' use. Two(2) bedrooms designated for staff use. All four (4) bedrooms, in use by clients, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for clients' use. All three (3) bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 107.8 and 114.1 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.Common Areas: These included the living room and dining area. The common areas were properly furnished and have sufficient lighting. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area is located in the garage. No detergents or laundry hazardous supplies were present in the laundry area.
Clients Files: LPA conducted a file review of clients 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: Medication and Medication Records were review for proper documentation.
Exit interview conducted. Deficiency issued and copy of this report delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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Document Has Been Signed on 12/07/2023 03:06 PM - It Cannot Be Edited


Created By: Mariana Agban On 12/07/2023 at 02:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CREBS COMPASSION HOME
FACILITY NUMBER: 197610112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds:Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients...This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA oberved knive in the unlocked kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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POC cleared the knive was locked up.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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