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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610247
Report Date: 03/04/2022
Date Signed: 03/04/2022 11:17:29 AM

Document Has Been Signed on 03/04/2022 11:17 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:PHIBA HOMEFACILITY NUMBER:
197610247
ADMINISTRATOR:KAWOOYA, DAVIDFACILITY TYPE:
735
ADDRESS:20112 LANARK STTELEPHONE:
(818) 617-0594
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 4CENSUS: 0DATE:
03/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Herbert AmanyaTIME COMPLETED:
10:30 AM
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A Pre-Licensing & Infection Control visit was conducted today by Licensing Program Analysts (LPA) Michael Cava. LPA met with the administrator, Herbert Amanya and stated the purpose of the visit. This is a change in location application. Currently the facility is vacant

The tour of the physical plant was conducted at 9:00am and the following were noted:

The main door is the only entrance being utilized for entry. LPA has advised the applicant to insure that there will be a sign on the door that everyone entering at the facility must wear a mask and must be screened. The screening area is located near the entrance. LPA observed a sign in sheet, hand sanitizer, gloves and masks. LPA was screened by staff upon entry. All staff were observed to be wearing a mask.

The facility submitted an approved Mitigation Plan and it was approved on 3/21/21 for it's current licensed facility located in Sylmar (facility #197607849).

Signs to wear a mask and other COVID 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with covers.

The facility has a designated visitor's area at the backyard. The facility has a sufficient supply of PPEs.

Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 120 degrees F. Towels and washcloths will not be shared. The licensee will supply a sufficient amount of personal hygiene items.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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: PHIBA HOME
FACILITY NUMBER: 197610247
VISIT DATE: 03/04/2022
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Common Areas: LPA toured all common areas to insure everything is in good repair. The facility maintains a comfortable temperature at 75 degrees F. LPAs observed a current fire extinguisher maintained in the kitchen, that is fully charged. The last charge date was in September 2021. The smoke/carbon monoxide detectors are operational. There are no issues with Fire Clearance.

Outside areas: LPAs toured the outside area of the facility to insure passage ways are clear of obstruction.There are no bodies of water which is unsecured.

The garage will be kept locked and inaccessible to residents.

Food Inspection: LPA conducted an inspection of the kitchen. According to the applicant, perishable and non-perishable food will be moved from their previous facility to this facility once they become licensed. LPA observed the food storage and preparation areas to be clean and free of pests. Cleaning supplies, pesticides or toxins will be stored and and kept inaccessible to residents.

Laundry: Laundry area is located in the hallway. Applicant will maintain enough linen and will be changing weekly or more if need.

Pursuant to CA code of Regulations Title 22 or Health and Safety Code, the facility physical plant is compliant and ready for licensure. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
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