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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610118
Report Date: 04/07/2021
Date Signed: 04/07/2021 03:36:58 PM

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:CASA DE MADERAFACILITY NUMBER:
197610118
ADMINISTRATOR:BROWN, DEWALTFACILITY TYPE:
740
ADDRESS:324 WAPELLO STREETTELEPHONE:
(626) 926-3519
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:10CENSUS: 0DATE:
04/07/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:DeWalt Brown, AdministratorTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an announced Pre-Licensing visit to this facility and met with applicant DeWalt Brown, Administrator. Currently there are no residents in care. Due to the situation surrounding the Corona Virus Disease 2019 (COVID-19) and to implement mitigation measures, today's visit was conducted virtually with the use of Zoom. Visit was conducted on 4/7/21. Component three was also conducted on 4/7/21.
The video call consisted of a tour of the physical plant. LPA inspected the facility for fire safety, personal accommodations and services, medication procedures, and food service. Facility has five bedrooms. All five bedrooms will be shared. There are five bathrooms. Fire clearance is approved for 10 ambulatory residents. LPA observed bedrooms and bathrooms to be clean. Bedrooms had appropriate linens on the beds, appropriate window coverings with screens, and appropriate furniture. Hot water was observed by LPA and administrator at 117 degrees F. The facility smoke alarm system and carbon monoxide is operable. Medications will be locked in a closet. Chemicals and cleaning solutions will be locked and stored under the kitchen sink. All knives and sharp objects will be locked in a kitchen drawer. There are no bodies of water on the premises.
LPA toured all common areas. LPA observed home to be clean and furniture to be in good condition. LPA did not observe any obstructions throughout the facility.
A telephonic exit interview was conducted, and a hard copy of the report was provided via email for signature. LPA will notify Centralized Application Unit regarding the completion of the pre-licensing visit and the completion of component III,
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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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