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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610118
Report Date: 12/16/2023
Date Signed: 12/16/2023 03:49:55 PM


Document Has Been Signed on 12/16/2023 03:49 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 MADERAFACILITY NUMBER:
197610118
ADMINISTRATOR:BROWN, DEWALTFACILITY TYPE:
740
ADDRESS:324 WAPELLO STREETTELEPHONE:
(626) 926-3519
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:10CENSUS: 1DATE:
12/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Sonja JohnsonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Sonja Johnson for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 12:40 PM and the following was noted:

There is one entrance being utilized at the facility. The facility has a total of three (03) bedrooms and three (03) bathrooms currently occupying one (01) resident. Two (2) rooms are shared rooms, and one (01) room is private. The facility is fire cleared for ten (10) ambulatory residents. The facility is currently occupying one (01) ambulatory resident.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a swimming pool/body of water with required fencing and locking mechanism. The garage is currently being used for parking. The washer and dryer are located downstairs. Laundry detergents, cleaning agents and other toxins are inaccessible to residents.

Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

Living and dining room furniture were also checked. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide detectors are hardwired, interconnected, and observed to be operational. Fire extinguisher is located near the kitchen, observed to be full and last inspected on 05/09/2023.
(continued on LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2023
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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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: 12/16/2023
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The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 109.1°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

LPA observed medication and first aid kit to be locked and inaccessible to residents.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.


SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023
LIC809 (FAS) - (06/04)
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