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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610206
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:21:48 AM

Document Has Been Signed on 11/22/2021 10:21 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:GUDEA INC.FACILITY NUMBER:
197610206
ADMINISTRATOR:BANOS, SELVAFACILITY TYPE:
735
ADDRESS:11246 STRATHERN STTELEPHONE:
(747) 272-3093
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 4CENSUS: 0DATE:
11/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Selva BanosTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a PRE-LICENSING visit to the above address 11246 Strathern, Sun Valley, CA, 91352. LPA met with Administrator Selva Banos. Upon entry, LPA was COVID screened with temperature check and sign in sheet. The inspection included, fire safety, personal accommodations, building and grounds, furniture/equipment, food service, and medication procedures. Fire Inspection was approved on August 13, 2021 which met fire department requirements for (4) ambulatory rooms (only). Facility sketch, emergency disaster plan, complaint procedures, personal rights, emergency exit plan, emergency phone numbers, and COVID, CDC, and Department of Public Health signs were visually posted.

The physical plant was toured inside and out with Administrator Selva. The facility is a one level home, with (4) bedrooms; with (1) room used for staff, and isolation room if needed for positive COVID cases. Facility has (2) bathrooms. Food supply was inspected and observed, and storage areas, cabinets, pantries, cupboards counters, and refrigerator were clean and appropriate for food preparation. Knives and medication will be stored in cabinets located in the kitchen and hallway area. Appliances were clean and functional, and utensils, plates, and cups were in good repair. Cleaning supplies, poisons, toxins and chemicals will also be locked and stored. There was enough supply of linens and towels, which were stored individually in the client bedrooms. Hygiene products were also available.

The common areas included the dining, living, bathroom, and client bedrooms. Doors and passageways were clear and unobstructed. Walls, ceilings, floors, window screens and all other rooms were clean, in good repair, and appropriately furnished.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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: GUDEA INC.
FACILITY NUMBER: 197610206
VISIT DATE: 11/22/2021
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Client rooms observed to have a mattress with pad, sheets, pillow, bedspread, dresser, closet space, and chair. Bathrooms were clean had functional fixtures, with soap and towels and grab bars. The water temperature measured at 110.0 degrees Fahrenheit. The back yard is completely fenced with a gate easily accessible and unlocked. There was no swimming pool or other bodies of water. No other visible hazards around the surrounding grounds.

Smoke detectors and carbon monoxide were operating correctly. Fire extinguisher is fully charged. Telephone system was working. First aid kit inspected. Garage area was locked and secured with extra refrigerator, and laundry equipment. Staff and client files were completed and stored in a locked cabinet. Mitigation plan will be emailed to LPA.

Exit interview, COMP III conducted/completed, and report issued to Administrator. There were no corrections needed, and facility is ready to be licensed and vendorized by Regional Center.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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