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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610172
Report Date: 07/30/2024
Date Signed: 07/30/2024 12:39:16 PM

Document Has Been Signed on 07/30/2024 12:39 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/
DIRECTOR:
CHAMBERS, TAMMY SHURELLFACILITY TYPE:
735
ADDRESS:27457 CAMP PLENTY RD.TELEPHONE:
(661) 309-4666
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91351
CAPACITY: 4CENSUS: 0DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Tammy ChambersTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual inspection of the facility. LPA met Administrator Tammy Chambers and explained the reason for the visit. The current census is (3); and during the visit all clients were working and in program.

A tour of the physical plant of the inside and outside was conducted.

Kitchen: The kitchen appeared clean and the appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; and properly stored. The facility has (2) extra refrigerators, stocked with food. Knives and detergents were stored in locked drawers and cabinets. Properly labeled medications were locked in a cabinet near the kitchen. Bedrooms: There were four private bedrooms designated for clients' use; and (1) room used for staff office. All bedrooms were properly furnished, with bedding and linens, as well as sufficient lighting. Bathroom: There were two bathrooms designated for client' use. Both bathrooms properly supplied with soap and towels, as well as functional fixtures; including grab bars. Hot water temperature 107.4 degrees Fahrenheit. Cleaning supplies were kept in locked cabinets and garage. Common Areas: These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards, with shaded furniture for clients. There is no a swimming pool in the backyard. All smoke alarms were tested and operating properly; doors have alarms. The fire extinguisher was fully charged. First aide had Licensing requirement items. Fire and earthquake drill was conducted 06/2024.

Client records. 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 07/30/2024
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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 were no errors observed.


Exit Interview conducted and report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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