197610235-5-17-2023-31-AS-TCAS-CRWQ5F-20230517115152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610235
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:53:19 AM

Document Has Been Signed on 05/17/2023 11:53 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:	WYSE HOME		FACILITY NUMBER:	197610235
ADMINISTRATOR:	LABEODAN, TAYO		FACILITY TYPE:	737
ADDRESS:	35158 WYSE ROAD		TELEPHONE:	(626) 500-1430
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91390
CAPACITY: 4		CENSUS: 1	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	LaQuencia Davis & Cesar Gomez		TIME COMPLETED:	12:15 PM

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Licensing Program Analyst (LPA) Tuesday Cabiness, and Licensing Program Manager Troy Agard, along with Regional Center staff, Royce Remelius (Community Services Specialist), Xochitl Aragon (Quality Assurance Supervisor, Ari Stark (Quality Assurance Specialist), and Venus Rodriguez-Khorasani, M.A.Ed. (Community Services Manager), conducted an annual inspection. Everyone arrived at the facility at 9am and met with LaQuencia Davis the Administrator. Shortly after, the Regional Director Cesar Gomez arrived during the inspection. The current census is (1). During the visit, LPA did not observe any licensing regulation postings throughout the visit. LPA was informed, due to the client’s behavior, the facility is unable to keep them on the walls.

A physical plant tour of the facility inside and outside was conducted with Administrator, LPA, LPM, and Regional facility staff. The following common areas: living, dining, kitchen, resident bedrooms, and bathrooms were inspected to ensure the facility was in compliance with Title 22 Regulations:

Kitchen: LPA observed a Licensing requirement of (7) day nonperishable, and (2) perishable, with extra refrigerator stocked with food, in the garage. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, that are stored in the kitchen and locked and stored in the garage. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (4) bedrooms. All bedrooms were properly furnished and supplied with appropriate bedding and linens. There were sufficient linens observed and available. Bathrooms: There are (3); all were clean, with soap and towels. Hot water measured at 106.0. degrees Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. There was no swimming pools or other bodies of water. All exit doors have alarms; all were operating.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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: WYSE HOME	FACILITY NUMBER: 197610235
	VISIT DATE: 05/17/2023

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Fire extinguisher fully charged. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors are operating properly.

Record review: A complete record review of staff and residents were conducted. All required documents in files.

Infection/Mitigation Control Review: The common areas were observed to be clean, including resident rooms, and staff and visitor bathrooms. Soap and towels, and hand washing signs were visually posted. The facility has cleaning procedures and protocols in place, which include staff cleaning common areas throughout the day.

PPE supplies were inspected and have over (30) day supply. The facility continues to implement the best practices for the facility; to ensure the health and safety of residents and staff. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview conducted, and copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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