197610118-5-10-2022-31-AS-RVAA-CEAUGE-20220510153413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610118
Report Date: 05/09/2022
Date Signed: 05/10/2022 03:34:38 PM

Document Has Been Signed on 05/10/2022 03:34 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:	CASA DE MADERA		FACILITY NUMBER:	197610118
ADMINISTRATOR:	BROWN, DEWALT		FACILITY TYPE:	740
ADDRESS:	324 WAPELLO STREET		TELEPHONE:	(626) 926-3519
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	10	CENSUS: 1	DATE:	05/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Nicola Ross, Administrator		TIME COMPLETED:	03:05 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) Rosaura Valenzuela conducted an unannounced Required One (1) year Infection Control inspection to the facility. LPA met with Administrator Nicola Ross and explained the reason for the visit. A tour of the physical plant was conducted at 12:20pm and the following was noted: There is only one entrance being utilized at the facility. Sign in sheet, hand sanitizer, and masks are available upon entry. The facility had submitted and approved Mitigation Plan. The facility has a designated visitors' area in the sun-room. The facility has sufficient stock of PPE in the basement. The facility has three (03) bedrooms and three (03) bathrooms currently occupying one (01) resident. Two (2) rooms are shared rooms and one (01) room is private. Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguishers are located on the first and second floor. Continuation- See 809-C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

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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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: CASA DE MADERA	FACILITY NUMBER: 197610118
	VISIT DATE: 05/09/2022

NARRATIVE

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There is no body of water at the facility.

Laundry area is located in the basement, laundry detergents, cleaning agents and other toxins are stored there. It was observed to be locked.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the shower and toilet. The hot water temperature was measured at 120 degrees F. There was enough clean linen available in stock at the cabinet.

Medications- LPA observed medication in a cabinet to be locked and inaccessible to the resident. There was one complete first aid kit

Exit interview conducted. A copy of this report was issued and signature obtained.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

LIC809 (FAS) - (06/04)

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