197610178-9-2-2021-31-AS-AARO-C6H8ZC-20210902225720

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610178
Report Date: 09/02/2021
Date Signed: 09/02/2021 10:59:54 PM

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:	ANNIKA GRACE CARE HOME		FACILITY NUMBER:	197610178
ADMINISTRATOR:	BATUIAN, JOZAM LATAYAN		FACILITY TYPE:	740
ADDRESS:	6338 W AVENUE J11		TELEPHONE:	(818) 802-8004
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 0	DATE:	09/02/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Jozam Latayan Batuan		TIME COMPLETED:	01:25 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) Angelica Arambulo conducted an announced visit to the facility. LPA met with applicant Jozam Batuan. His administrator certificate # 6057138740. The facility has a fire clearance for 5 Non ambulatory and one bedridden in room 1. pre checklist was reviewed with the applicant during the visit. Upon entry LPA temperature was checked and documented. PPE supplies were at the entry way and tour was given. The facility is a one story home with 5 bedrooms. 4 for resident use and one staff room. There are 2 1/5 bathrooms for residents use. The rooms had required lighting, furniture and linens. All bathrooms had grab bars, non-slip rugs and towels. The linen cabinet had additional towels, bed sheets, and blankets. The kitchen was checked and there is food supply for 7 days non-perishable and 2 days perishable. There is a cabinet stocked with bottled water and emergency food. Each cabinet through out the kitchen and bathrooms had the magnetic lock which automatically locks . Cleaning solutions are locked away and separate from food items. Knives are locked away under the kitchen sink. The medication cabinets have a lock and has the first aid kit that is complete. The stove had the plastic cover for the knobs as extra security for any dementia residents. Water temperature was measured at 115.9. The smoke detector was checked and is hard wired throughout the facility. The smoke detector is a combination with the carbon monoxide detector. There is a fire extinguisher that is full in the dining area. The front and back yard are well manicured and maintained. There is sign's in the home for COVID 19 PROCEDURES and is visible for visitors and residents. Ombudsman poster is up in the common area. The visitor sign outside the home will need to be updated for essential workers and outdoor visitations. The common areas were well lit and furnishings all appropriate for resident usage.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Angelica Arambulo	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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: ANNIKA GRACE CARE HOME	FACILITY NUMBER: 197610178
	VISIT DATE: 09/02/2021

NARRATIVE

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Activity schedule is posted and will be updated to residents capabilities. There is a menu posted along with the emergency disaster plan. The facility floor plan giving emergency exits. Residents personal rights, Theft and loss policy, facility house policy, and resident council notifications. A register of residents shall be updated once the facility is in operation.

LPA will be emailing the report to the applicant along with a checklist of documents he needs for staff files, facility files and resident files. Administrator / applicant had his file there with his first aid certificate and other required papers. The applicant will be in contact with LPA for assistance with his paperwork. email verified to be correct. home phone line will be connected next week and applicant will update LPA. The phone on file is his personal cell phone. A staff schedule will be updated and submitted along with the liability insurance once license is approved.

Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Unit (CAU). You will be notified by the CAU Analyst when your license has been approved.

You are not allowed to begin operating until you have been notified that your license has been approved by the CAU Analyst. Failure to comply could affect approval of your license.

Exit interview held.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Angelica Arambulo	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC809 (FAS) - (06/04)

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