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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610200
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:05:52 PM

Document Has Been Signed on 11/21/2023 02:05 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
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: 4DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Moses WakabiTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 10:25 am. LPA disclosed to the staff the purpose of the visit. The administrator was present at the facility.

LPA conducted a tour of the physical plant at approximately 10:38 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the living room, dinining room, and kitchen. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be clean, sanitary and have adequate seating for residents. Office area in dining room.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the four (4) residents currently residing there. Two (2) days of
perishable food observed. The freezer is stocked with meats and frozen foods. Food pantry located in laundry room stocked with vegetables and boxed foods. Resident medications locked in closet near entry. Sharps and toxins are stored and locked under kitchen sink and observed to be locked an inaccessible to residents. There is one (1) fire extinguishers in facility attached to the wall in kitchen and observed to be charged.

Laundry room is located in separated room at side of kitchen. The appliances observed to be functional. The locked cabinets above washer and dryer contain laundry detergents and supplies.

(Cont to 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PROVIDENCE RESIDENTIAL HOME
FACILITY NUMBER: 197610200
VISIT DATE: 11/21/2023
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(Cont. from 809)

The facility has a total of four (4) bedrooms and two (2) bathrooms for residents in care.

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 107.5- and 110.5 -degrees Fahrenheit.

Backyard has the following: Covered patio with two (2) tables and chairs, and small sofa chair. Patio furniture observed to be in good repair with adequate seating for residents.

Attached Garage but no indoor access: Additional refrigerator, PPEs and storage.

Smoke detector/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards.

At approximately 11:30 am, LPA reviewed four (4) resident files and four (4) random staff files. Resident files included current Individual program plans (IPP) and/or Individual services plans (ISP). Staff files had the appropriate trainings to include first aid/CPR, and CPI (Crisis Prevention and intervention).

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


Exit Interview Conducted /Copy of the Report Issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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