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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610172
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:32:54 PM

Document Has Been Signed on 11/07/2023 12:32 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:HOME OF CHAMPIONS LLCFACILITY NUMBER:
197610172
ADMINISTRATOR:CHAMBERS, TAMMY SHURELLFACILITY TYPE:
735
ADDRESS:27457 CAMP PLENTY RD.TELEPHONE:
(661) 309-4666
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91351
CAPACITY: 4CENSUS: 3DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Tammy Chambers - AdministratorTIME COMPLETED:
12:30 PM
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A Required Annual visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with the administrator Tammy Chambers and explained the reason for the visit. This is a North Los Angeles Regional Center vendored facility level 3.

At 10:04 AM, A tour of the physical plant was assessed and the following was noted:

The only entrance being utilized is the main front door, there is a sign at the main door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted inside immediately upon entrance. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has four (4) private client bedrooms and one (1) bathroom. There is one (1) additional bedroom and one (1) bathroom designated for staff use double as an as an office. There is no body of water in the facility.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at 108.1°F and within the required range. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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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: HOME OF CHAMPIONS LLC
FACILITY NUMBER: 197610172
VISIT DATE: 11/07/2023
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet below the sink.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is set at 71°F and observed to be within the required range.
Fire extinguisher There is a fire extinguisher located in the kitchen. Extinguisher was observed to be full and last bought on 01/07/23. Dual smoke alarms/carbon monoxide are tested and observed to be operational. Garage is attached to the house but there is no access from the inside. The garage is also use as laundry room and storage of old equipment and tools.

Client records. All three (3) clients record were reviewed for current IPP and/or Needs and Service plans. physician report, admission agreements and P & I funds. Client records appeared to be complete and current. Staff records were reviewed. Staff has criminal record clearances and associated to this facility. Staff records appear to be complete and current.

Medication was observed to be inaccessible and stored in a secured cabinet located in the kitchen. There is a complete First Aid kit located in the kitchen.



Disaster drill was last conducted on 11/05/23. Required posting are observed to be complete and current and displayed properly at the facility.

There is no health and safety issue during this visit. Exit interview conducted. Copy of this report issued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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