197610235-4-25-2022-31-AS-TSMH-CDTU2Y-20220425151242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610235
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:12:51 PM

Document Has Been Signed on 04/25/2022 03:12 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:	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:	DATE:	04/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Tayo Labeodan, Administrator		TIME COMPLETED:	03:15 PM

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At 10:50 am Licensing Program Analyst (LPA) Tihesha “Lynn” Smith made a subsequent visit to this facility to complete pre-licensing component III with Tayo Labeodan.

LPA Smith conducted initial pre-licensing visit on 04/18/2022 at 10:30 AM. At time of visit the facility was not ready to be licensed. The following corrections must be made:

· Water temperature adjusted from 135 degrees to 105-120 degrees.

· Provide First Aid Kit

· Locked area to store client medications

· Locked area to store sharps

· Locked area to store cleaning supplies

· Locked area to store client and staff records

· Provide bathroom skid mats, curtains, paper towels, hand washing signage

· Provide adequate seating in the living room area

· Provide items for recreational activities (books/games and etc.)

· Add sufficient quantity of linens and towels

During today’s visit LPA observed the hot water temperature has been adjusted to 109.0 degrees.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WYSE HOME	FACILITY NUMBER: 197610235
	VISIT DATE: 04/25/2022

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(Cont from 809)

There are two (2) new first aid kits stored in locked kitchen. The medications will be stored in locked box and in locked upper kitchen cabinet near first aid kits. The sharps with be locked in top drawer near double oven. The cleaning supplies are stored under locked kitchen island cabinet. The staff records will be stored in office/garage in locked file cabinet. Client records will be stored in locked upper kitchen cabinet below client medications. Bathrooms have paper towels, soap, hand washing signage and trash cans. LPA observed a sufficient supply of towels and hygiene supplies locked in the laundry room cabinet. There is also a two (2) day supply of perishable and non-perishable foods in the kitchen.

ARF PowerPoint presentation conducted.

The following items are needed to complete the application:

1. Each bathroom need shower curtains and non-skid mats for residents' use
2. Add sufficient quantity of linens
3. Provide adequate seating in the living room area
4. Provide items for recreational activities (books/games and etc.)

In general, the facility is clean, safe, sanitary and in new condition. The facility is in compliance with Title 22 regulations.

Exit Interview was conducted. A copy of this report was given to the administrator

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC809 (FAS) - (06/04)

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