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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610155
Report Date: 10/12/2023
Date Signed: 10/12/2023 02:36:12 PM


Document Has Been Signed on 10/12/2023 02:36 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:MAMELEH & TATELEH'S UPSCALE LIVINGFACILITY NUMBER:
197610155
ADMINISTRATOR:CHO, DANIEL D.FACILITY TYPE:
740
ADDRESS:18847 THORN CREST COURTTELEPHONE:
(213) 392-2325
CITY:LOS ANGELESSTATE: CAZIP CODE:
91351
CAPACITY:6CENSUS: 6DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Irma Parchejo TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced annual inspection. LPA was greeted by caregiver Irma Parchejo, who allowed LPA to enter. Administrator Daniel Cho was notified and arrived shortly after. LPA observed COVID signs outside the front door, and upon entry, several more signs, with a hand washing station, sign in sheet, and electronic thermometer. Licensing signs and postings located throughout the facility.

A physical plant inspection of the inside and outside was conducted with LPA and the Administrator.

Kitchen: LPA observed Licensing requirement of (7) day nonperishable, and (2) perishable, with extra refrigerator and freezer located in the garage area; stocked with food. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, knives, and hygiene products, were locked and secured located in the garage. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (5) bedrooms for residents; with (1) shared, and (4) private. All bedrooms were properly furnished and supplied with appropriate bedding and linens. There were sufficient linens observed and available. Bathrooms: There are (3); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at 119.7 degrees Fahrenheit. Surrounding Grounds: The facility has outdoor furniture, for resident's comfort. There are no swimming pools or bodies of water. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry room. All exit doors have alarms and were operating properly. Fire extinguisher fully charged. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors were tested and operating properly.
Record review: A complete record review of staff and residents were conducted, all required documents were in file; including updated training records for staff. Medication records were reviewed with no errors.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MAMELEH & TATELEH'S UPSCALE LIVING
FACILITY NUMBER: 197610155
VISIT DATE: 10/12/2023
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Infection/Mitigation Control Review: Upon entry, LPA enter facility and there was a sign-in sheet with a cleaning station. Soap and towels, and hand washing signs were visually posted and located in all bathrooms. The facility has sufficient stock of PPE supplies. The facility has cleaning procedures and protocols in place, which include staff cleaning common areas throughout the day. The facility has documentation of all vaccination records for staff and residents. There are no current staffing issues; during today's visit, LPA observed (2) staff on duty. New clients or new staff must have a negative COVID test before entry.

The facility continues to implement the best practices for the facility; to ensure the health and safety of residents and staff. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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