197610200-10-19-2022-31-AS-ERIS-CKCPFH-20221019111646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610200
Report Date: 10/19/2022
Date Signed: 10/19/2022 11:16:53 AM

Document Has Been Signed on 10/19/2022 11:16 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PROVIDENCE RESIDENTIAL HOME		FACILITY NUMBER:	197610200
ADMINISTRATOR:	WAKABI, MOSES		FACILITY TYPE:	735
ADDRESS:	16742 OSBORNE STREET		TELEPHONE:	(747) 236-4373
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 1	DATE:	10/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Moses Wakabi		TIME COMPLETED:	11:30 AM

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Licensing Program Analysts (LPA) Evelin Rios conducted an Annual Required visit and inspection of the facility. LPA was granted access by staff Sauda Nalubega and the administrator, Moses Wakabi met us shortly after and LPA explained the reason for the visit.

At 9:40am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual. They are interconnected. The fire extinguisher is located by the dinning area, next to the kitchen. The charge date is 8/26/2021.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Cleaning supplies also stored in and kept locked and inaccessible to the residents in kitchen cabinet.

Bedrooms: There were four (4) bedrooms designated for clients' use. All four bedrooms, were properly furnished with appropriate beddings and linens with sufficient lighting. Only two out of the four are used by clients.

Bathrooms: There are two (2) bathrooms designated for clients' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 105-120 degrees Fahrenheit.

Common Areas: These included the living room, dining area and office area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Properly labeled medications were locked in a hallway off the dinning area for the client who is in the hospital. The laundry room is located by the kitchen and detergents and cleaning supplies are kept locked in a cabinet. Cleaning supplies also stored in the laundry area were kept locked and inaccessible to the residents.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PROVIDENCE RESIDENTIAL HOME	FACILITY NUMBER: 197610200
	VISIT DATE: 10/19/2022

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. LPA observed storage shed kept looked. Two side gates on both sides of the home that lead to the front yard were closed but not locked and are available for use in case of an emergency.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation for client that is currently in the hospital.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

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