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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610200
Report Date: 10/14/2021
Date Signed: 10/14/2021 11:35:33 AM

Document Has Been Signed on 10/14/2021 11:35 AM - 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:PROVIDENCE RESIDENTIAL HOMEFACILITY NUMBER:
197610200
ADMINISTRATOR:WAKABI, MOSESFACILITY TYPE:
735
ADDRESS:16742 OSBORNE STREETTELEPHONE:
(747) 236-4373
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 0DATE:
10/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:MosesTIME COMPLETED:
11:45 AM
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Licensing Program Analyst conducted an announced pre-licensing visit on this day.

The facility is a four-bedroom, single-story home licensed to care for four ambulatory clients. LPA was greeted upon arrival and confirmed that COVID screening protocols are in place at the facility.

LPA utilized the Adult Residential Facility (ARF) Prelicensing inspection tool to verify compliance with all inspection domains. The facility's common areas and bedrooms/bathrooms were clean, well-furnished and functional. Facility appliances were in working condition, hot water temperature measured between 105 and 120 degrees, and appropriate storage areas were present for cleaning supplies, medications and other hazardous materials. At 11:00 a.m. the administrator removed some cleaning agents from the unlocked outdoor shed to the locked facility garage.

No other deficiencies observed, or corrections required at this time.

Administrator completed component 3 already in the Woodland Hills Regional Office in 2019, it is waived for this visit.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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